FACTORS ASSOCIATED WITH ANAEMIA AMONG PREGNANT WOMEN: A

CASE STUDY OF MANDERA COUNTY REFERRAL HOSPITAL

ABDIRIZAK HAJI MOHAMED

HND -3-2383-1/2014

A RESEARCH THESIS SUBMITTED IN PARTIAL FULFILLMENT FOR THE

REQUIREMENT OF THE CONFERMENT OF THE MASTER’S DEGREE OF

HUMAN NUTRITION AND DIETETICS AT KENYA METHODIST

UNIVERSITY

October, 2019
 DEDICATION

I dedicate my thesis to my family whose inspiration especially my brother Abdiwahab

Mohamed who helped me financially and encouragements has made me reach this level

of my life.

ACKNOWLEDGEMENT

I acknowledge with gratitude the support I received from my brother Abdiwahab

Mohamed, who tirelessly encouraged me to complete this work. My mother Fatuma for

her kind support always helped me to finish this project in good time Thanks for your

ii
prayers and encouragement. Many thanks to my supervisors; Dr. Joyce Meme and Dr

Makobu Kimani for their continuous assistance in the course of writing this project.

I wish also to sincerely thank Mandera Hospital staff and management for their support,

encouragement during data collection data not forgetting my research assistant

Abdirahman Sharif. God bless you all.

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 LIST OF ABBREVIATIONS

ASAL Arid and Semi-Arid Lands

CDC Centre for Disease Control

(HBM) Health Belief Model

HIV Human Immunodeficiency Virus

IDA Iron Deficiency Anaemia

IFAS Iron Folic Acid Supplementation

KAP Knowledge, Attitudes and Practices

KDHS Kenya Demographic and Health survey

KEMU Kenya Methodist University

(TRA) Theory of Reasoned Action

MOH Minister of Health

WHO World Health Organization

iv
 ABSTRACT
Anaemia is the most common medical related disorder during pregnancy. It has become a
major health related problem in the majority of developing nations, where deficiency in
nutrition, worm infestation and malaria are common. Both pregnant and non-pregnant
women are the most affected by this disorder. Majority of women lack adequate
knowledge regarding causes of anaemia in pregnancy, and the majority of mothers know
that diets containing inadequate iron are the main cause of the anaemic condition. The
study sought to examine factors associated with causes of anaemia among pregnant
women in Mandera referral Hospital. The study adopted a descriptive cross-sectional
research design. This study was a quantitative method the study target population was
pregnant women in Mandera Referral Hospital. The estimated number of women
pregnancy women aged 15-49 is estimated to be 3651 and they formed the target
population for the study. The study adopted simple random sampling and convenience
sampling techniques. A structured questionnaire was administered to all eligible women
to determine their socio-demographic and KAP on anaemia. The primary data was
collected by the use of the structured questionnaire that has been developed by the
researcher. The data was then presented in frequencies, cross tabulations and diagrams.
Most of the respondent were in their second or other pregnancies as they had been
pregnant before [205, 65.7%] compared to those in their first pregnancy [107, 34.3%] (p
=0.000) while on the stage of their pregnancies, slightly more than half [161, 51.6%]
were in their second trimester compared to 25.3% in their first trimester (p >0.05). Half
of the respondents indicated that they had a total of two pregnancies, 80(25.6%) had three
pregnancies. That majority (68.9%) of the respondents were not aware of iron (p value
<0.05) and further that 44.2% of the respondents knew the sources of iron compared to
55.8 who neither knew or not sure on the sources (P value >0.05). Majority (199, 63.8%)
faced challenges to access and availability of iron rich foods. Most of the women (249,
20.2%) were aware of Vitamin A and further 96.2% were not aware of the various sources
of Vitamin A and these responses were significant at 5%. Majority 46.2% and 42.3% took
foods rich in Vitamin A on weekly and daily basis. The study also recommends that there
should be interventional measures to educate the mothers and to initiate importance of
iron folic acid supplements.

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 DEFINITION OF KEY OPERATIONAL TERMS

Anaemia: Refers to the concentration of haemoglobin in the body, below two

standard deviations, and also the median of a healthy population of the

same age, and with a specific reference mean.

Attitude: Refers to the perceptive, emotional, motivational as well as cognitive

beliefs, which have either positive or negative influence on an individual’s

practice or behaviour. The feeding habits of individuals are influenced

their motivations, emotions, perceptions or thoughts. The attitude

influences the future behaviour regardless of individuals’ knowledge, and

helps in explaining why individuals adopt a certain practice with no other

substitutes. The term belief, attitude and perceptions can be interchanged

Knowledge: It is the individual’s ability to understand the causes, signs and symptoms

and the prevention measures of anaemia. It is the ability to remember

nutrition and food related terminologies, facts and information.

Practices: Refers to an observable action of individuals, which can affect their

nutrition, for instance, washing of hands, feeding, food selection and

cooking. Behaviour and practice are terms that can be interchanged, even

though practice is connoted as long-standing practice.

Public hospitals: refers to a hospital that is under the ownership of the government and

receives funds from the government.

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 CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Anaemia is amongst the world’s most prevalent problems in health (Khadija, 2006).

Research has shown that the problem has affected approximately two billion people in the

world, which translates to a third of the population in the world, hence; it has become an

important problem in public health. In almost every developing nation, between a third

and a half of children and female population has been referred as anaemic. Anaemia has

as well been regarded as the most common medical related disorder during pregnancy,

particularly in developing nations, where nutritional deficiency conditions like malaria

and worm infestation are common. The condition mostly affects both pregnant and non-

pregnant women.

Chronic anaemia, particularly when concomitant with chronic deficiencies of

micronutrients can have major effects on children and women, and can as well affect the

attendance of children to school, performance as well as physical work. Iron deficiency

has become a rampant nutritional health deficiency condition which has become a burden

among people and governments in the global context. Nutritional related anaemia is the

most rampant type of anaemia globally. It is caused by iron; folate and vitamin B12

insufficiencies (Khadija, 2006). Causes of anaemia are inclusive of nutritional

deficiencies, genetic factors, and also infectious agents. Therefore; deficiency of iron is

perhaps the greatest and significant due to physiological changes related to pregnancy,

that lead to a demand for extra iron that is required for foetus transfer (James et al.,

2003).

1
A study by World Health Organization (WHO) projected that in countries that are

developing; the rates of prevalence in expectant women usually range from 40% to 60%.

About a half people with anaemia suffer from deficiency of iron. Deficiencies in folate

and other reasons usually account for a large percentage of other types of anaemia.

Maternal anaemia during pregnancy is normally taken to be a risk factor relating to

pregnancy outcomes that are poor and could lead to problems threatening the lives of

foetus and mother. Present knowledge shows deficiency in iron during the pregnancy

period as a risk factor for miscarriage succeeding low birth weights and probable sub-

standard neonatal health. The importance of this is to have information to adopt a positive

attitude and practices in nutrition; most causes of anaemia are nutrition related.

A previous study done in India found that lower knowledge and attitude about anaemia

during pregnancy increases risk in about five times. This accelerates and worsens during

pregnancy increasing the anaemia risk to about six times. Some of the possible risk

aspects that were shown to increase anaemia were knowledge and attitudes regarding the

anaemic condition in pregnant women. Infections that include; hookworm, malaria and

other helminths also take part in anaemia pathogenesis during pregnancy. Expectant

women are more susceptible to Malaria infections in endemic populations and this places

them at a higher risk of anaemia. Anaemia may increase the prevalence of postpartum

haemorrhage and predispose to puerperal infection. In developing countries, the two

conditions are the leading factors of death in pregnant women. Lack of a balanced diet,

especially insufficient intake of fruits, vegetables and animal sourced foods are the major

causes of iron deficiency and poor birth outcomes (Hassan et al., 2013).

2
Diets among low income societies majorly comprise of legumes and cereals which are

slightly lower in iron. These foods are a source of non-heme iron. This type of iron is

slightly complex and difficult to be absorbed in the human body. The heme iron is

absorbed two to three times better than the non heme iron. In addition, little amounts of

heme iron necessitate the absorption of non-heme iron. These diets are common among

pregnant women and a major determinant of the iron capacity that is absorbed in their

bodies. The legumes and the whole grains contain phytic acid which form insoluble

compounds that prevent iron absorption hence deficiency in iron which results into

anaemia.

Majority of women have inadequate knowledge on causes of anaemia during pregnancy

and most mothers are aware of the fact that inadequate iron containing diet as the cause

of anaemia. Regarding the knowledge on sources of rich iron containing foods, most of

the women in ASAL regions and in slum regions are characterized with low

socioeconomic status are not aware of the that green leafy vegetables, meat, fish, egg are

good sources of iron. Most women in the ASAL regions have no access to fresh supply of

green vegetables and heavily rely on meat for iron. Coupled by their inadequate

knowledge of proper and adequate nutrition, this has increased their risk of developing

anaemia. However, early detection and effective management of anaemia can contribute

substantially to reduction in maternal mortality. The rolling out of nutrition education on

consumption of healthy foods during pregnancy and strengthening supplementation of

iron and folate in pregnant women will ultimately reduce mortality of anaemia and other

micronutrient, low birth weight among women.

3
Inadequate knowledge concerning causes of anaemia in pregnancy is a common

phenomenon among women. Additionally, they have little or no knowledge regarding

iron rich diet; this remains the main cause of anaemia. Most of the women living in

ASAL and slum regions are characterized with low socioeconomic status and are not

aware of iron rich sources of food such as eggs, meat, fish and green leafy vegetables.

Most women in the ASAL regions have no access to fresh supply of green vegetables and

heavily rely on meat for iron. Coupled by their inadequate knowledge of proper and

adequate nutrition have increased their risk of developing anaemia. However, early

diagnosis and effective management of anaemia can contribute significantly to reduction

in maternal mortality. Nutrition education and sensitization of balanced healthy diet

before and during pregnancy as well as supplementing pregnant women with iron and

folate help reduce mortality related anaemia, micronutrient and low birth weight in

women.

A number of demographics, social economic factors have been closely associated with

nutritional diet practice and diversity that many pregnant women adopt. They include

occupation, age, level of education, income generated and their marital status. Level of

education has closely been linked to the choice of diet and eating habits of the pregnant

women. Patterns in dietary intake are closely determined by occupation, parity, level of

education and age. An increased maternal age and high maternal education are often

associated with a healthy and a diversified diet in pregnant women. Women with less

education and are not working record a higher parity and are likely to indulge in

unhealthy and less diversified diets.

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1.2 Statement of the Problem

Globally, deficiency of iron is the leading cause of anaemia in women during pregnancy.

Anaemia prevalence in Kenya is moderately high and pregnant women have a poor

nutritional status and anaemic .On attendance of antenatal clinics ,pregnant women are

administered with iron supplements .However, the struggle to fully eradicate anaemia

continues to be really high as well as foetal morbidity and maternal mortality in Kenya

due to low knowledge of anaemia and type of foods they consume (WHO and CDC,

2008).Many households in Mandera county are vulnerable to food and nutrition

insufficiency, poverty, illiteracy and drought have led to minimal access to essential

services to the majority of the inhabitants of the county. The anaemia related problems

are accelerated by factors such as difficulties in the access of quality maternal health

services which include antenatal services, delivery services and post-natal services.

Moreover, marginalization, poor health care, lack of transparency and accountability,

negative cultural and religious practices are other factors affecting efforts put in place to

curb anaemia.

A pregnant woman suffering from anaemia is likely to experience problems during

pregnancy and can result to serious complications to the mother and the foetus.

Deficiency in iron leads to preterm deliveries, inferior neonatal health and low birth

weights. In Kenya, the prevalence of anaemia is about 54% whereas a total of 70% of

pregnant women in the country suffer from anaemia. This creates the need to evaluate the

factor associated causes of anaemia in pregnant women and their knowledge about good

diet intake. Most of the studies done in Kenya have sought to evaluate the extent of

anaemia and none has been done to and did not ascertain the KAP on anaemia among

5
women. A study by Khadija (2006) carried out in Kakamega established prevalence of

anaemia in pregnancy at 25.7%. Sawe (2001) conducted a study in Kericho District and

established a prevalence of anaemia during pregnancy at 24.5%. Currently, there is no

study which has been done to evaluate the knowledge and practices of nutritional causes

of anaemia among women in northern part of Kenya. Therefore, this study will seek to

determine the factors associated with anaemia among pregnant women attending

Mandera Referral Hospital in Mandera County.

1.3 Justification of the Study

In developing countries, prevalence to anaemia is about 15%. However, in Africa,

anaemia prevalence especially to pregnant women ranges from (35-75%) (WHO, 2010).

In Sub Saharan Africa, the burden of anaemia disease continues to increase due to the

additional iron requirements from puberty to menopause. A report by (WHO, 2010)

indicates that during pregnancy, 58.27 million women in the world are anaemic.

Insufficient knowledge on the causes and prevention measures of anaemia may lead to

high morbidity and maternal mortality among pregnant women, and pregnant women

have a poor nutritional status that lead to anaemia. The Ministry of Health has laid out

policy on Iron supplementation to all women attending antenatal clinic and this can be

effectively done if proper knowledge and strategies set out towards nutritional anaemia

among pregnant women are well documented.

The micronutrient deficiencies and anaemia remain as major concern for pregnant

women; this will lead to reduced mental capacity, poor physical performance and fatigue

during pregnancy. This study will go a long way into obtaining information relating to

anaemia in knowledge level and its application among pregnant women in the Mandera

6
 Referral Hospital where micronutrient deficiency shows very high due to insufficient

knowledge and poor practices among the pregnant women at Mandera Referral County

Hospital, hence it will help in paving the way forward towards objective intervention

measures among women in Mandera county. There is a need to carry out the study to

identify key challenges and gaps in giving knowledge and positive attitude, thus the study

will be aimed at determining the Nutritional causes of anaemia among pregnant women

attending Mandera Referral Hospital.

1.4 The Purpose of Study

The study is aimed at identifying factor associated causes of anaemia in pregnant women

in Mandera County. The study seeks to help the health workers to improve on service

delivery to prevent the cause anaemia in pregnant women and to provide awareness

towards anaemia and look for ways of intervention.

1.5 Objectives of the Study

1.5.1 Main Objective

To examine the factors associated with anaemia among pregnant women, a case of

Mandera County Referral Hospital.

1.5.2 Specific Objectives

i. To determine the socio demographic characteristics of pregnant women attending

Mandera County Referral Hospital.

ii. To determine the intake of dietary iron among pregnant women attending Mandera

County Referral Hospital.

iii. To examine the intake of dietary folate among pregnant women attending Mandera

County Referral Hospital.

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iv. To examine the intake of dietary vitamin A among pregnant women attending

Mandera County Referral Hospital.

1.6 Research Questions

i. What is the socio demographic characteristics of pregnant women attending Mandera

County Referral Hospital.?

ii. What is the intake iron among pregnant women attending Mandera County Referral

Hospital?
iii. What is the intake folate among pregnant women attending Mandera County Referral

Hospital.?
iv. What is of intake of Vitamin A among pregnant women attending Mandera County

Referral Hospital?

1.7 Hypothesis

H0: Pregnant women in Mandera County have no knowledge, attitudes and practices of

anaemia.

H1: Pregnant women in Mandera County have knowledge, attitudes and practices of

anaemia.

1.8 Significance of the Study

The study findings will be important to various stakeholders. It will provide the common

causes of anaemia such as parasitic infestations such as malaria and hookworm, the

predisposing factors, age, low socioeconomic status and illiteracy which were critical in

anaemia preventions, the knowledge level in nutritional causes of anaemia in pregnant

women. Alternatively, the study will avail key information to other researchers and

academicians by providing the KAP on the nutritional causes of anaemia in Kenya, since

few studies have been carried out in Mandera Referral County Hospital and this will

8
improve the information to the researchers and the government which has been

advocating and providing free iron supplementation to the pregnant women in Kenya

(KDHS, 2008/2009).

The study may provide key information to the mothers on the need of iron

supplementation before and during their pregnancy period as well as the sources of folate

and iron. This would contribute to their overall wellbeing through intake of adequate iron

and folic nutrients. This may help the residents to observe healthy living so as to reduce

the disease burden among pregnant women through their knowledge.

1.9 Limitation of the study

The study was majorly focusing on pregnant women attending Mandera Referral

Hospital. The study foresaw challenges during data collection due to the security reasons

that have affected the region. The region is also characterized by high illiteracy rates

among women and this posed challenges in data collection.

1.10 Delimitation of the study

To overcome the challenges, the researcher used research assistants who administered the

questionnaire using the local dialect to overcome the language and illiteracy barrier. The

data collected was collected at the healthcare facility where security was provided.

9
 CHAPTER TWO

LITERATURE ANALYSIS

2.1 Introduction

This section reviews literature associated with factors contributing to prevalence of

anaemia among pregnant women. The literature review was collected from different

sources books, document analysed from hospitals, journals and internet. In the world,

anaemia prevalence amongst pregnant women is at 55.9%, anaemia as particularly

prominent in South Asia. In India, anaemia is one of most problematic nutrition health

related challenges. The prevalence of anaemia is between (33- 89%) in pregnant women.

There are a number of factors that lead to the increase of anaemia in sub-Saharan Africa.

An iron and folate deficient diet is amongst the leading causes of anaemia as well as

malaria and hookworm’s infections. The rapidly increasing human immunodeficiency

virus (HIV) has significantly led the rising cases of anaemia.

2.2 Global and National Prevalence of Anaemia

Anaemia, as the state of disease, is manifested through decreased red blood cells

presence, which is coined with in decrease concentration of haemoglobin. The

complexity of Anaemia is related to various probable pathophysiological causes that

range from genetic and environmental, in addition to shifting epidemiological

surveillance levels. Anaemia currently remains a community health concern that is

borderless, and that has great impacts on health, socio-economic states as well as

preferential prospects for those that are impacted directly. Regardless of the possibility of

intervention as well as treatment, the disease remains to be a great source of morbidity

and mortality at regional and global levels. In the global context, anaemia has affected

10
between a quarter and a third of the total population in the world, even though researchers

have provided estimates of risk populations, indicating about a 50%-80% incidence level,

principally as a result of deficiency of iron.

Pregnancy is normally an exceptional, exciting as well as a joyous moment in the life of a

woman because it demonstrates an astounding nurturing and creative powers possessed

by a woman as she also provides a connection to a better tomorrow. Lacking of nutrition,

coined with other various factors leads to numerous difficulties throughout the pre-birth

period. A major difficulty often noticed in mothers during the antenatal period in

countries that are developing countries like India is prevalence of the anaemic condition

throughout pregnancy. Anaemia refers to a reduction in haemoglobin levels in the body,

to lower than the standard range of about 13.5 gm/dl in men, 11.5 gm/dl in women, and

11.0 gm/dl in children as well as in pregnant women). Anaemia has now become a

renowned community health related problem related to proliferated risk of mortality and

morbidity, particularly in women that are pregnant. Anaemia arises from multiple causes,

including nutrition (for instance vitamins as well as mineral insufficiencies), in addition

to non-nutritional causes sometimes frequently co-occurring.

Generally, the commonly causal factors include; deficiency of iron, deficiency of folic

acid as well as deficiency of vitamin B12. Anaemia that arises from deficiency of iron is

normally taken to be a main contributor to the worldwide disease burden. In those

countries that are developed, it has been projected that about 3% suffer from anaemic. In

developing countries, this value could be approximately 50%, which has ultimately

contributed to high maternal mortality rates. The inadequacy of foods that are nutritious,

food related taboos, as well as cooking and eating customs usually play a major role.

11
Anaemia can be prevented through making women to understand the existence of the

problem as well its causes.

Globally, anaemia cases have continued to fall over the past few years. A 12% anaemia

decline was experienced between the year 2005 and 2011in non-expectant women and

(43- 38%) decline among pregnant women. This indicates that there has been significant

success in the efforts to prevent against anaemia. Therefore, it is necessary that countries

review their national health policies, infrastructural structures and resources so as to

implement strategies to prevent and control anaemia (Morris et al., 2009). In 2003, the

World Bank conducted a study in developing countries and established anaemia to be the

eighth leading cause of disease in teenage girls and women (World Bank, 2003).

A study by the World Health Organization- World Health Statistics (2005) estimated the

average prevalence of anaemia in the world to be 41.8%. Research studies have been

conducted and they have revealed that Asia and sub Saharan Africa have the highest cases

of anaemia (WHO, 2005). Africa has an estimated 57.1% prevalence of anaemia while

South East Asia has a prevalence of 48.2%. On the other hand, anaemia prevalence in

America has an estimated prevalence of 24.1% in anaemia cases while in Europe it is at

25.1%. Africa has the highest anaemia cases in the world. In Nigeria, the anaemia

prevalence ranges between (30-40%). Urban areas in Ethiopia have an anaemia

prevalence of 35.9% while the rural areas have a prevalence of 56.8%. Ethiopia as a

whole has an anaemia prevalence of 41.9% (WHO, 2005).

In actual figures, the World Health Organization has suggested that roughly 900 million

children and women have been affected by anaemia in the global context. A current

approximation of about 38% global anaemia prevalence in women that are pregnant,

12
coined with above 50% of problems relating to deficiency of iron have clearly

highlighted the way children and women have extremely been affected by anaemia.

During pregnancy, anaemia has been linked to greater possibilities of occurrence of

preterm labour, post-natal contagion rates, low birth weight, infant/maternal mortality as

well as low Apgar scores. Occurrence of anaemia has been termed as the utmost in the

African continent, reportedly with a prevalence of approximately 58% in expectant

women (which is about 17 million) and 69% in infant (84 million).

A study conducted by Rajeev Kumar Yadav and Swamy (2014) revealed that the

prevalence of Anaemia was high in the course of the immediate post-natal stage, and also

at the age of 1 to 4 years in young children, and this recognizes a probable relationship

between the pre and post-natal states of anaemia. When focusing on children particularly,

anaemia is termed as a life threatening condition that shortens people’s lives. It as well

impacts expressively on the potentials that people have in life. Universally described

health problems linked to anaemia in young children include; decreased cognitive ability,

impaired growth as well as decreased motor development.

Severities in anaemia cases have been much more widespread in developing countries.

Conditions such as low birth weight, foetal physical and mental disability, maternal and

prenatal mortality. On the extreme ends, death of infants is experienced. Often, anaemia

is worsened by postpartum haemorrhage and exposes the mother to puerperal infection

which is a leading cause of maternal mortality in developing countries.

A study in Pakistan postulated that anaemia remains to be a major public health challenge

in the rural areas of Pakistan. A study by WHO revealed that 30% and 53% of women

and children respectively were already at risk of anaemia. From the study, women were

13
more prevalent to anaemia than children. The rural areas of Pakistan experienced low

haemoglobin tests for earlier prevention and treatment. This has been attributed to lack of

anaemia awareness among the communities, often due to low education levels. The costs

involved in the testing of anaemia were established as a major challenge hindering the

communities from seeking early anaemia testing. During the study, free testing was

offered to the participants and the Point of Care System was adopted. Individuals were

screened from their homes hence eradicating the barrier of transport and movement from

their homes to the clinic. The study concluded that the Point of Care Testing improved the

access to anaemia testing and diagnosis. This has also proven success in the testing of

chronic, infectious and acute conditions in the rural areas (Akhtar, Ahmed, Ahmad, Ali,

Riaz & Ismail, 2013).

A study by Ayenew, Abere & Timerga (2014) has shown that in Ethiopia, around 9.4% of

the mothers were anaemic 64.3% were mildly anaemic, 32.1% were moderately anaemic

and 3.6% were severely anaemic. The findings of this study were similar to those found

in Nigeria 40.4%, Tanzania 47.4%, India 74.8 and Ethiopia 38.2%. The differences in the

studies were attributed to the differences in social cultural, economic and demographic

characteristics of the various countries. The high prevalence of anaemia in Isparta,

Turkey was attributed to thalassemia. The high prevalence in India was due to the high

rural population.

A study by Sohail, Shakeel, Kumari, Bharti, Zahid, Anwar & Ali (2015) found out that

malaria was a high risk factor for anaemia with a prevalence of 5.4 % at antenatal clinics

and delivery units. In addition, the prevalence of anaemia at the antenatal clinics was

86% whereas in the delivery units it was at 72%. Cases of severe anaemia were at 13.6%

14
and 7.8% at antenatal clinics and delivery units respectively. Much higher anaemia

prevalence was observed in patients who also had malaria. The study recommends

prompt diagnosis and administration of drugs to pregnant women who report cases of

parasitemia and asymptomatic infection of plasmodium vivax either in pregnancy or

during delivery. Early diagnosis of these diseases results to reduced risk of anaemia.

Figure 2.1: Worldwide Prevalence of anaemia 1993-2005

Source: WHO Global Database on Anaemia (2008)

A research was undertaken in South Eastern Africa in the year 2006 and revealed that

Tanzania had an anaemia prevalence of 74.4%, Mozambique-58%, Coastal Kenya-75.6%

and Rural Zaire -76% (Jane et al., 2007).

In Malawi, between July 2007 and June 2008, a study done on the urban population of

women who sought antenatal services at St. Elizabeth Hospital in Blantyre, 57.1% were

found to be anaemic. A study by (James et al., 2008), in Kenya, indicated that Kakamega

15
had an anaemia prevalence during pregnancy of about 25.7%. A study in Kericho District

showed that the area had an anaemia prevalence of about 24.5%.

According to The Global Micronutrient survey done in May to October 2009, Kenya,

prevalence of moderate anaemia in pregnancy was 54%, while almost 70% of pregnant

women were moderately anaemic. This is despite routine supplementation with iron for

all pregnant women who attend antenatal clinics (James et al, 2008). About 17% of

Ethiopian women are anaemic during their reproductive age. In addition, 22% of the

anaemic women are pregnant. Regardless of the adverse effects the disease has on the

population, well documented data is unavailable on this regard (EDHS, 2011).

A study by Ara et al. (2019) in Bangladesh revealed that micronutrient deficiencies were

the main causes of anaemia. Children and pregnant women were found to be more

vulnerable. Anaemia is one of the leading public health concerns in the region. Pregnant

women are the most vulnerable to anaemia. This micronutrient deficiency has escalated

and has had a devastating effect on the general economic growth of Bangladesh.

Following a survey in the region, the deficiency and anaemia prevalence was much

higher in slum dwelling school children, pregnant and lactating mothers. This deficiency

can be attributed to low quality and less diversified diets, poverty, little knowledge on

dietary choices and societal inequalities.

According to Sari et al. (2001) a research study on the risk factors and severity of

anaemia was carried out in Kisumu District and observed that the respondents who had

developed obstetric complications, a total of 22% were diagnosed with anaemia. Poor

pregnancy care and ailments during the pregnancy period were cited to be the leading

causes of the high anaemia prevalence. Sanitary, social and economic conditions were

16
fundamental in the prevalence of anaemia. In Kilifi, a research study was carried out and

showed that 10% of the pregnant women who had undergone the antenatal clinic suffered

from severe anaemia (Hb<7g/dl) with 76% having Hb, 11g/dl. Hookworm infestation,

folate deficiency and malaria were the main causal effects of anaemia. HIV infections

also played a key role in the prevalence of anaemia (Sari et al., 2001).

Anaemia has significant effect on social and economic development. It is one of the

major challenges facing the health sector in developing countries. It is one of the leading

causes of complications during pregnancy in Africa. Death in pregnant women as well as

foetal mortality is a major challenge facing developing countries as a result of anaemia.

Anaemia causes about 115,000 maternal and 591,000 per natal deaths in a year. Causes of

anaemia during pregnancy can be as a result of teenage pregnancy, short pregnancy

intervals, malnutrition, multiple pregnancies, reduced appetite and vomiting which is a

characteristic of many pregnancies. In low socio-economic settings, anaemia is a major

phenomenon during pregnancy. Multiparity, multigravida women are at a high risk of

developing anaemia as compared to other categories of women. Consumption of tea as a

beverage has also been linked to anaemia as it inhibits iron absorption.

In pregnancy, anaemia is the greatest causal factors of the worldwide disease burden,

where anaemia caused by iron deficiency contributes to more than a half of all reported

cases. Commonly, anaemia has effects on over 70% of pregnant women in most African

Nations. In Kenya, there is a very high prevalence of anaemia during pregnancy, which

ranges between 45% and 55%. About six in every ten women that are anaemic normally

suffer from anaemic, resulting to about 2 in ten maternal related deaths and two in ten

prenatal deaths in Kenya.

17
A study in Pumwani Hospital, Kenya, to determine the relationship between anaemia and

HIV/AIDS during pregnancy was carried out. The study sought to establish the socio

economic characteristics as well as the dietary intakes of the pregnant women. The study

found out that anaemia was more prevalent among women who were HIV positive. The

risk factor for anaemia was two times more in HIV positive patients as compared to the

uninfected pregnant women. The study concludes that anaemia was more prevalent

among the women from low socio economic backgrounds as they consumed low iron

foods. The study therefore recommends that there should be enhanced sensitization of

iron consumption and supplementation to women living with HIV/AIDS during the

prenatal clinics (Okube, Mirie, Odhiambo, Sabina & Habtu, 2016). The services should

be extended even to areas characterised by low economic status.

In areas where malaria is endemic, intermittent preventive treatment with effective anti-

malarial drugs and the distribution of insecticide-treated bed nets need to become

implemented on a large scale as per The Roll Back Malaria; a global partnership founded

in 1998 by World health Organization (WHO), The United Nations Development

Programme (UNDP), The United Nations Emergency Children’s Fund (UNICEF) and

World Bank with the goal of halving the malaria burden by the year 2010.Other

preventive measures include ensuring comprehensive obstetric and social history at the

antenatal clinic, proper dietary counselling on proper sources of iron available to the

community, family planning services encouraging at least three year intervals and

discouraging eating of soil during pregnancy. Profound IDA has serious consequences for

both the woman and the foetus and requires prompt intervention with intravenous iron.

This is especially important for the safety of women who for various reasons oppose

18
blood transfusions. Whenever possible, the cause of anaemia should be determined before

instituting treatment. Blood transfusion can only be used where the haemoglobin is

dangerously low, where there is risk of further dangerous fall like in rapid bleeding or

where no other effective treatment of anaemia is available.

2.3 Nutritional Causes of Anaemia

2.3.1 Iron Deficiency

Deficiency of iron commonly results from an imbalance of iron intake, insufficiency of

iron stores as well as the body losing iron, hence; the iron available becomes inadequate

to for fully supporting red blood cells production. Anaemia arising from iron deficiency

hardly leads to death, though its effect on the health of humans remains greatly

significant. In developed countries, anaemia is often identified easily and treated fast;

nevertheless, it is habitually disregarded by most of the physicians. Centrally, anaemia

has become a great health related problem that touches main parts of a population in the

majority of the developing nations.

Largely, preventing and successfully treating anaemia arising from iron deficiency has

remained distressingly inadequate in the global context, particularly amongst

disadvantaged children and women. Iron deficiency anaemia is the most common type

contributing to 50% of all anaemia, and results to almost a million deaths per year, with

three-quarters of these deaths occurring in Africa and south East Asia. Close to 500,000

maternal deaths ascribed to childbirth or early post-partum occur every year, with vast

majority occurring in the developing world. Anaemia poses a 5-fold increase in overall

risk of maternal death related to pregnancy and delivery.

19
Iron is known an important constituent of haemoglobin within the red blood cells, and is

also a component of myoglobin within the muscles, containing about 60% of overall iron

within the body. Iron is as well essential for the operation of numerous mechanisms

within the cell that include; enzyme based procedures, synthesis of DNA, and also

generation of energy in the mitochondria. In grownups, the body comprises of 3–5 grams

of iron, and 20 to 25 mg being needed on daily basis red blood cells production as well as

cell based metabolism. Since nutritional consumption is usually limited to 1–2mg per

day), some additional bases are required for homoeostasis of iron, like reprocessing of

aged red blood cells in the macrophages, exchange of iron in enzymes as well as stores of

iron. Approximately 1–3mg iron is lost on daily basis due to menstrual cycle,

desquamation of skin, urinary excretion and sweating. Since iron lacks a regulation

pathway in its excretion, intestinal absorption, dietary intake as well as recycling of iron

need to be regulated finely.

Nutritional iron is often present in two formulae: that is; haem as well as non-haem iron.

Iron is normally presented Fe²+ (ferrous iron) within the haemoglobin and in the haem

formula, and is available in animal foods, including poultry, meat as well as seafood.

Non-haem form of iron (Fe³+) is available in vegetarian diets (cereals, black tea, dried

fruit, cacao and so forth). Haem iron contributes approximately 10–16% of overall intake

of iron in populations that eat meat, but, since it is commonly absorbed in a better way at

the rate of about 15–35%, as opposed to the non-haem iron form, it accounts for greater

than 42% of overall iron absorbed.

Haemoglobin is a key component involved in carrying of oxygen in the blood. One of the

key components of haemoglobin is iron. Iron can be acquired through the intake of an

20
iron rich diet and when iron is recycled from old blood cells. Usually, reduced iron blood

amounts results to reduced carrying capacity of oxygen by the blood resulting to

interferences in the physiological bodily processes. An estimate of an average amount of

840-1210 mg of iron is given as the required amount to be absorbed during pregnancy.

When this is not achieved, maternal haemoglobin falls to 11 g/dl and below. When the

haemoglobin level is 10 mg/dl or below (haematocrit under 33%), a case of iron

deficiency is likely to be diagnosed (Brabin et al., 2008).

Patients suffering from anaemia resulting from iron deficiency can show signs linked to

all types of anaemia, while in most cases they are linked to particular symptoms as a

result of deficiency of iron. Skin pallor, conjunctivae as well as nail beds are the most

common symptoms. The effectiveness of these symptoms in diagnosis is improved when

physicians have the ability of ascertaining if their availability is an alteration from

normality in a patient. Other signs are normally due to hypoxic operation including:

exertional dyspnoea that progresses to lack of breath in the rest period, headaches,

vertigo, tachycardia, syncope as well as cardiac systolic flow murmur.

In cases that are severe, patients may experience dyspnoea during rest, haemodynamic

instability as well as angina pectoris. Clinical related characteristics of deficiency of iron

in anaemia are dependent on the disease severity, comorbidities, chronicity, age as well as

the onset speed. In a number of cases, anaemia becomes asymptomatic, and can only be

detected after conducting laboratory based haemoglobin concentrations measurement.

Deficiency of iron deficiency, particularly has major effects on epithelial cells, and

accompanied by a quick turnover. It leads to skin roughness, damaged and dry hair and

finger nails that are spoon-shaped). In some cases, loosing tongue papillae takes place,

21
particularly in patients that suffering from mild-to-moderate deficiencies of iron, and

remains a worthy gauge of deficiency length.

Globally, over two billion people suffer from iron deficiency, with pregnant women being

the largest affected category. Problems of inefficient systems, definition related

difficulties and lack of accurate and reliable data are some of the challenges marring

efforts aimed at combating anaemia. Anaemia that occurs during pregnancy is due to iron

deficiency (Brabin et al., 2008). In industrialized countries; about 14% of pregnant

women ail as a result iron deficiency anaemia (IDA). The developing countries have a

higher rate which ranges between (35-75%) with an average of 56% (WHO, 2006).

In the year 2010, worldwide prevalence of anaemia stood at 39·9% (that is, above22

billion had been affected), and deficiency of iron was noted to be the main cause. WHO

had provided estimates that; between the year 1994 and year 2005, the global anaemia

occurrence stood at 24∙8% within the overall population, ranging from approximately

12∙8% in men, to 48∙6% in young children at the age of between 0 and 5 years.

Occurrence ranged from 31.3% amongst women, 42.8% in pregnant women, while it was

noted that about 24.7% of people above 60 years had anaemia. In 1995-2011, global

anaemia occurrence reduced by approximately 4–6% in young children at the age of 0–5

years and both pregnant and non-pregnant women at the age of15 to 49 years.

Deficiency of iron is the commonly occurring dietary deficiency; however, vigorous,

population-based researches have been conducted in this area. For example, in the United

States, studies on iron deficiency prevalence range from 4.8% to 20%. Nevertheless, at a

worldwide phenomenon, the least anaemia burden linked to deficiency of iron was

identified in Canada and USA (2.7% of envelope). In a number of regions, including the

22
central Asian region (65.8%), the south Asian Region (56.4%) as well as the Andean

Latin America (63.5%), a very great percentage of the burden of anaemia resulted from

deficiency of iron. Data relating to iron deficiency epidemiology in relation to anaemia

are quite untrustworthy, particularly because the disease is frequently credited to

deficiency of iron, regardless of its cause. WHO (2016) has estimated that about 50% of

anaemia cases globally result from deficiency of iron, though subgroup and regional

disparities normally exist. In a number of studies that have been carried out in the

previous 5 years, anaemia due to iron deficiency anaemia has recorded a prevalence of

about 20%.

Poor iron intake is increased by some dietary contents, such as phytates and phenolic

compounds which reduce iron absorption which ultimately results to increased cases of

anaemia. Often, iron deficiency is likely to occur in a person who is suffering from other

nutrition related deficiencies. However, this is neglected hence the increased cases of

anaemia. In this regard folic acid deficiency, riboflavin, Vitamin B12, Vitamin A and

copper results to an increased risk of anaemia as they play a vital role in haemopoietin

(Brabin et al., 2008).

During pregnancy, the bodily iron requirements usually increase, hence more

constraining to a woman who is already iron deficient. Pregnancy results to increased

physiological demands for iron unlike in other physiological processes. Pregnant women

highly need iron to supplement their regular iron losses, to cater for the required red

blood cells capacity and the demand requirements for the foetal placental unit. Iron

supplements should be recommended to be taken together with orange juice as it

increases its absorption. Various studies have shown that substantial iron supplementation

23
during early pregnancy stages has a positive effect on foetal growth and development.

Parenteral iron supplementation results to faster haematological recovery due to its

variations in oral iron tolerability, absorption and compliance. It is administered through

intravenous or intramuscular methods.

Globally, one of the major public health challenges is deficiency of iron among the

communities. Deficiency in iron is manifested through general ill health and body

weakness, premature deaths and bodily foetal abnormalities. Iron deficiency has been

known to lower one’s capacity to perform hence leading to serious economic growth and

development challenges in a region. Anaemia has affected approximately a third of the

global total population; and half of reported cases are attributed to deficiency of iron.

Anaemia has become a great public health difficulty globally affecting child and maternal

mortality, health-care professionals’ referrals as well as physical performance (Jane, John,

Mahshid, Nita, Karita & Megan, 2007).

Children at the age of 0 to 5 years, women at the age of childbearing are mainly at risk of

contracting anaemia. A number of chronic illnesses are habitually linked to anaemia

resulting from deficiency of iron, particularly the chronic disease of kidney, chronic

failure of heart, inflammatory bowel diseases and cancer. Assessment of serum ferritin,

serum soluble transferrin receptors, transferrin saturation as well as transferrin receptors–

ferritin indices are additionally correct compared to typical red cell indices in iron

deficiency anaemia diagnosis. On top of the detection for and management of the iron

deficiency causes, treatment approaches are inclusive of; prevention methods like

fortification of food fortification as well as supplementation of iron.

24
2.3.2 Folate Deficiency

Deficiency of Folate is a very great problem affecting women in the global context. This

deficiency results principally from insufficient nutritional intake. Characteristic intakes of

folate are sub-optimal in most women’s diets during their childbearing ages, and also

intake of Folate is additionally affected by poor bioavailability as well as cooking losses,

that are estimated to range from approximately 51% to 83%. Grains fortification with

folic acid has led to increased intake of Folate in various developed nations, although

such food types are normally unavailable in Ethiopia. Deficiency of Folate could as well

be a result of medical circumstances that amplify the requirement of folate, or lead to

improved folate excretion in situations of lactation, pregnancy, malabsorption,

alcoholism, liver disease; kidney dialysis, particular anemias as well as medications

interfering with metabolism of folate.

Folate is a key player in neurotransmitter synthesis and regulation of gene expression. It

plays a crucial role in cell division and amino acid metabolism. The one carbon

metabolism process for physiological nucleic acid synthesis is a function of the folate

substance. In pregnant women; an increase in folate consumption is necessary for cell

proliferation. Folate also aids the growth of the uterus and placenta tissue as well as the

expansion of the mother’s blood capacity. Bodily folate requirements are 5-10 folds

higher in pregnancy than in non-pregnant women, hence expectant mothers are at an

increased risk of folate deficiency (Cook, 2004).

Folate nutrients’ deficiency has been associated with numerous risks to health. Serious

cases of folate deficiency have often resulted in the megaloblastic anaemia condition.

Sub-optimal preconceptions concerning folate nutrients intake increases spontaneous

25
clinical risks of abortion in women, sub-optimal birth weight, neural tube deficiencies as

well as preterm birth. Disorders related to digestion like diarrhoea, loss of weight and

appetite may possibly occur with Folate deficiency, as also can happen with body

weakness, sore tongue, palpitations of the heart, headaches, forgetfulness, behavioural

conditions and irritability. Furthermore, there has been emerging evidence that deficiency

of folate could be associated with osteoporosis development due to increased

homocysteine level. Therefore, deficiency of folate has remained a significant issue in

public health, predominantly in women at the childbearing period.

In addition, folate deficiency results to an increase in the homocysteine substance in the

serum and is likely to cause heart related ailments. Alternatively, it may result to

pregnancy complications such as neural tube abnormalities during conception and pre-

eclampsia in the late stages of pregnancy. Pregnant women should take around 400μg of

folate in a day. Globally, deficiency in folate has been a major challenge. This deficiency

is as a result of inadequate folate intake (Cook, 2004). The ideal intake of folate in the

diet of many women in the childbearing age is very low and is further minimized during

cooking and poor bioavailability at an estimated rate of (50-82%).

Deficiency of folate is at present a major micronutrient deficiency, and is also a

worldwide concern of public health, particularly amongst women who are at the age of

child bearing. A study carried out by …..showed that deficiency of folate in women who

are pregnant women intensifies the neural tube defects (NTDs) risk, intrauterine

development hindrance, congenital heart deficiencies, premature births as well as oro-

facial cleft deficiencies in newborn children. The defensive outcomes of sufficient

maternal consumption of folate on the risks of having pregnancies affected with Neural

26
Tube Defects have been proven in interventional and observational studies. Systematic

reviews of 29 studies that evaluated the transformations in NTDs prevalence due to

compulsory fortification of folic acid food demonstrated a decrease in the Neural Tube

Defects occurrence due to compulsory strengthening, with the utmost declines observed

in Costa Rica, at 59% decrease, Argentina at 52% decrease, while in Canada there was

49% decrease.

The worldwide occurrence of deficiency of Folate in populations is not known due to

unavailability of information from various world parts. Most nations, particularly in

countries that are low income, do not regularly evaluate the status of Folate in the

population. In nations lacking information on the status of Folate, reported information

on deficiency of Folate is varied due to usage of diverse methods of testing, variable cut-

off choices as well as race heterogeneity, ethnicity or geographical regions. A Canada

based research through the post-obligatory period of fortification amongst women who

are pregnant generated an occurrence of 2% deficiency of Folate.

Worldwide data in relation to cognizance as well as usage of folic acid has been

inadequate, has mostly been reported from few studies that have been carried out in a

number of countries. A number of such researches have been reporting great cognizance

concerning folic acid, and some of them have been reporting low awareness levels. Great

awareness levels in relation to folic acid amongst women at the age of child-bearing were

established in researches done in the United States in Kansas State (85%), and also Texas

state (76%). Awareness levels of Folic acid amongst women who are pregnant that were

receiving prenatal care was established to be at very high levels (86%) in Australia. In

Nigeria, great awareness levels (62.8%) concerning folic acid amongst women who are

27
pregnant that were in search of prenatal care in some of the largest hospitals were

established. Some studies that were carried out in Chile established low levels of

awareness of folic acid at 44%. The usage of supplements of folic acid by women who

are pregnant was reported at 27% and 18%, correspondingly, in studies carried out in

Chile and the United States.

Developing countries have intensified efforts to fortify grains with folic acid so as to

increase folate intake. Deficiencies in folate can be as a result of other medical conditions

that result to an increased need or excretion of folate such as lactation, pregnancy, kidney

dialysis and certain types of anaemia, malabsorption and other medications that interfere

with folate metabolism (Cook, 2004). Deficiency in folate often leads to a number of

health related risks. An increased rate of folate deficiency often results to megaloblastic

anaemia. Little folate intake before conception may lead to still births, neural tube

defects, low birth weights and unforced abortions.

In South Africa, comparative studies relating to status of folate amongst childbearing

women in the stage of pre-fortification versus the stage of post-fortification revealed a

decrease in folate deficiency prevalence, ranging from 25.8% to 2%. Great folate

deficiency prevalence amongst women at the age of child-bearing was established in

researches carried out before mandatory flour fortification implementation in Ethiopia

(48%), and also in Benin (33%). Nevertheless, there exists limited data relating to folate

deficiency prevalence in Kenya.

In the Kenyan context, two types of intermediations iron and folate supplements for

consumption by individuals as well as mandatory fortification legislation of maize that is

28
milled as well as wheat flour have been utilized to improvement of status of folate in

populations. A combination Iron-folate supplements are regularly offered to women

during their initial antenatal care (ANC) visits (at below 16 weeks’ of gestation) with

intentions to prevent anaemia, nevertheless, they cannot reduce NTDs risk, since neural

tubes normally close at the age of 21-28 days after conception has taken place, before the

majority of women are aware of pregnancy. The Kenya Food, Drug and Chemical

Substances Act got amended in 2012 to comprise of compulsory fortification of folic acid

in maize as well as wheat flour. Media campaigns that promote the usage of flour that is

fortified flour have been done in order increase awareness, and also promote fortified

flours’ demand since 2012.

2.3.3 Vitamin B-12 Deficiency

Vitamin B12 is also referred to as Cobalamin, and is grouped amongst the eight B

vitamins. It plays a major role in promotion of metabolism in the cell, and is intertwined

closely with folate and another vitamin B. Since its discovery, and also characterization

Vitamin B12 for approximately 60 years is known to have played a fundamental role in

prevention of pernicious anaemia, and its lack or the presence of this disease is normally

termed as Vitamin B12 deficiency. Pernicious anaemia first attained its suitable eponym

due to the eventual deadly haematological and devastating neurological manifestations of

the disease and was later shown to be caused by autoimmune destruction of gastric

parietal cells and their product, intrinsic factor (also known as gastric intrinsic factor),

which is required for B12 absorption. Previously perceived as a dietary deficiency

disorder mainly resulting from the Vitamin’s mal-absorption and restricted only to the

old, predominantly those form the Northern European region, deficiency of B12 is

29
currently known as a global dimensions’ problem, commonly resulting from dietary

insufficiency, predominantly amongst women at the childbearing age as well as children.

Sources of Vitamin B12 include milk, meat and eggs. Deficiency in vitamin B12 can be

caused by the inability of the small intestine to absorb the nutrient. This may be due to

previous stomach surgeries, bacterial growth or any other intestinal disease. It is also

caused by tapeworms ingested from fish or its products. However, lack of the intrinsic

factor is the main cause for vitamin B12 deficiency. Lack of intrinsic factors normally

results to low absorption of vitamin B12. Anaemia as a result of vitamin B12 deficiency

is called pernicious anaemia.

Vitamin B12 deficiency is mainly manifested in the nervous system and blood. Classical

expressions of deficiency Vitamin B12 were initially recognized in the pernicious

anaemia condition, a cause which was unknown then. Ever since, the range has

considerably shifted, beginning with the new identification of neurological expressions

(like as motor and sensory instabilities (predominantly in the lower boundaries), ataxia,

cognitive degeneration resulting to psychiatric disorders and dementia). It is frequently

dominant and can regularly happen in the absence of haematological problems.

Additionally, the manifestations of subtler B12 deficiency, made complete possible

through assays’ introduction for metabolites methyl malonic acid (MMA) as well as

homocysteine in clinical practices. This has made the landscape broad of what could be

attributed to deficiency of Vitamin B12, though has opened a Pandora’s controversy box

relating to what might be taken to be actual. Clinical related deficiency of Vitamin B12

compared to metabolic inadequacy states of the vitamin. Progression from the normal

rates to clinical deficiencies goes through an inadequacy stage through which

30
biochemical indication of inadequacy of B12 in increased blood form and tissue degrees

of homocysteine and MMA and deteriorating B12 levels that are bound to transcobalamin

(also referred to holotranscobalamin). This precedes morbid manifestations’ expression I

case of deficiency. This situation has as well been referred to as ‘sub-clinical’ Vitamin

B12 shortage, and is linked to marginal or B12 intensities.

Deficiency of Vitamin B12 is greatly incidence amongst old people, largely rising above

60years at age between 21 and 23. Fundamental deficiency causes are varied and well go

beyond the 2–5% pernicious anaemia incidence amongst older people, about 10-15%

show sub-clinical deficiency of B12 that can frequently, though not at all times, be

standardized with therapy of Vitamin B12. The incidence is additionally greater in the

‘oldest-old’, where reports have shown that about 23–36% of individuals at the age of

80years and above suffer from deficiency of Vitamin B12. Flexible vulnerability across

diverse populations as well as racial groups has frequently been established.

Both Pregnancy and lactation change the status of maternal B12 in a way that it enables

B12 transfer to the infant as well as foetus. Intense anatomical and physiological

alterations happen in almost every organ in pregnancy, with significant results on

biochemical markers, therefore; confounding the micronutrient status evaluation and

limiting the usage of reputable orientation choices determined in women with less than

the reported limit levels that define deficiency in normal women. Certainly, this

escalation is dependent on the status of maternal B12, and is less in women consuming

supplements. This presents a great requirement for particular ranges of reference on the

basis of Vit-B12-replete (this is one which is supplemented to standard intensities) in

pregnant as well as lactating women. Relative to these alterations, the true occurrence of

31
Vit-B12 shortage in pregnant women is hard to measure, though it reportedly occurs in

<10% (in Brazil and Canada) to >75% (in parts of Turkey and India) of expectant women

33–35%. In one research, postpartum period, maternal circulation of Vitamin B12 level

was reported to be considerably greater than in non-expectant women. This could

certainly symbolize physiological adaptations to improve maternal B12 mobilization in

stores so that they can be transferred to the infant through accumulative levels of breast

milk.

Deficiency in vitamin B12 deficiency has an incidence of 10-28% in uncomplicated

pregnancies. Sources of vitamin B12 are mainly animal products. An estimated amount of

over 1000μg is available to fertile women who often have a balanced diet. During full

term, vitamin B12 in a foetus range between 25-50μg. About 20% of women indicate

signs of a significant reduction in vitamin B12 levels in the pregnancy period and this

accelerates in the third trimester. The vitamin B12 levels in the pregnant mother

determine the level of vitamin B12 in the foetus. Vitamin B12 is transferred through

active transport from the mother’s placenta into the foetal circulatory system which often

results in double the volume of foetal serum as compared to maternal serum capacity.

Deficiency in vitamin B12 leads to anencephaly, a condition where the foetus is born

without a brain and hence dies immediately after birth. A study by Shoran et al. (2009)

identified three anencephalic mothers and found that they had very low Vitamin B12

levels. This might have been the case as vitamin B12 is a key player in the metabolic

activities of the neural tissue. Other pathological conditions that take place as a result of

deficiency in vitamin B12 include neuronal death, demyelination and axonal

degeneration (Shoran et al., 2009).

32
Women who do not receive adequate dietary requirements are most likely to experience

vitamin B12 deficiency. Vitamin B12 plays a crucial role in DNA synthesis which is a

requirement for cell multiplication in foetal development. Other conditions caused by

vitamin B12 deficiency include hyperhomocysteinemia. Vitamin B12 is transferred from

the mother to the foetus by active transport across the placenta into the foetus circulatory

system which often leads to the foetal serum being double that of maternal serum levels.

Therefore, maternal vitamin B12 determines foetal vitamin B12 levels. Vitamin B12

deficiency can be treated through parenteral injections to replenish the body stores of

vitamin B12. Vegetarian diets are the main causes of vitamin B12 deficiency.

B12 shortage has recently emerged as a great concern in public health in most low-

income nations. A study carried out by …. recognized infants, infant children

as well as expectant women and lactating mothers as the most susceptible groups.

Approaches for preventing B12 shortage as well as its significance in public health could

be deliberated in a life-course theory. The status of Maternal B12 during the prenatal

period as well as cord blood concentration of B12 predict the offspring’s status well and

all the way into the early adulthood, and highlights an essential responsibility for vitamin

status in the mother to avert deficiency of vit-B12 in the future generations.

Outstandingly, this transgenerational sequence turns into a self-perpetuation if a foetus

happens to be female. This recommends that improvement of the nutrition in young girls

potentially improves the B12 status ‘legacy’ in a population for several generations, and

also reduces related morbidity levels. The status of Maternal B12 status is undesirably

influenced by combinations of foods that exist poorly in foods that are animal-sourced,

high fertility degrees as well as short inter-expectancy interludes, and is further

33
intensified by socio-cultural factors like early marriages coined with adolescent

expectancies, and dietary taboos during expectancy and lactation.

2.3.4 Vitamin A

Night blindness and an increase in maternal mortality are some of the conditions brought

about by a deficiency in vitamin A. Cases of premature births and intrauterine growth

retardation have also been attributed to vitamin A deficiency. Symptoms from a person

suffering from vitamin A deficiency include night blindness, exophthalmi (dry eyes,

failure to produce tears), keratomalacia (drying and clouding of the cornea with

ulceration), Bitot spots (keratin debris in the conjunctiva) and photophobia. Follicular

hyperkeratosis (excessive development of keratin in hair follicles) which occurs in the

presence of malnutrition is an indicator of vitamin A deficiency. Ocular changes can be

documented quantitatively using a dark adaptation test (like the papillary threshold test-

PTT) or using electro-retinography. Change in night blindness is accessed via a simple

before (the intervention) and after (the intervention or treatment) questionnaire (Milman

et al., 2003).

Vitamin A deficiency remains a public health problem among women, affecting an

estimated 19 million pregnant women, with the highest burden found in the WHO regions

of Africa and South-East Asia. During pregnancy, vitamin A is essential for the health of

the mother as well as for the health and development of the foetus. This is because

vitamin A is important for cell division, foetal organ and skeletal growth and maturation,

maintenance of the immune system to strengthen defences against infection, and

development of vision in the foetus as well as maintenance of maternal eye health and

night vision. Thus, there is an increased need for vitamin A during pregnancy, although

34
the additional amount required is small and the increased requirement is limited to the

third trimester. The recommended nutrient intake (RNI) of vitamin A for women during

pregnancy is 800 µg retinol equivalents (RE)/day, which may be difficult to achieve

through the diet alone in vitamin A-deficient areas. Dietary sources of provitamin A

include vegetables such as carrot, pumpkin, papaya and red palm oil; animal foods rich in

preformed vitamin A include dairy products (whole milk, yogurt, cheese), liver, fish oils

and human milk.

Although pregnant women are susceptible to vitamin A deficiency throughout gestation,

deficiency is most common in the third trimester due to accelerated foetal development

and the physiological increase in blood volume during this period. In a pregnant woman

with moderate vitamin A deficiency, the foetus can still obtain sufficient vitamin A to

develop appropriately, but at the expense of the maternal vitamin A stores. Vitamin A

deficiency may also occur during periods when infectious disease rates are high and/or

during seasons when food sources rich in vitamin A are scarce. The prevalence of night

blindness (a consequence of vitamin A deficiency) is also more common in the third

trimester of pregnancy, and populations with a prevalence ≥5% are considered to have a

significant public health problem with regard to vitamin A deficiency. It is currently

estimated that 9.8 million pregnant women are affected by night blindness worldwide.

There is some indication that low doses of vitamin A supplements given on a daily or

weekly basis, starting in the second or third trimester, can reduce the severity of decline

in maternal serum retinol levels during late pregnancy and the symptoms of night

blindness. One study has suggested that 12 weeks of supplementation is needed to

prevent decline in serum retinol levels.

35
Vitamin A is available in multiple vitamin formulations for prenatal care in some

countries. When provided alone, the compounds most commonly used are retinyl

palmitate and retinyl acetate in tablet form or oil-based solutions. Alternative forms of

delivery include fish liver oils, β-carotene, and a combination of β-carotene and vitamin

A. Recommended doses of vitamin A supplements are generally well tolerated by

pregnant women; however, vitamin A may become toxic for the mother and her foetus

when levels of intake exceed 10 000 IU daily or 25 000 IU weekly. Β-carotene, a

precursor of vitamin A, may be preferred over vitamin A supplements in pregnant women

because excess of β-carotene is not known to cause birth defects. The symptoms of acute

vitamin A toxicity include dizziness, nausea, vomiting, headaches, blurred vision, vertigo,

reduced muscle coordination, skin exfoliation, weight loss and fatigue. Toxicity generally

results from excessive ingestion of vitamin A supplements but regular intake of large

amounts of liver, although usually not a problem in vitamin A-deficient areas, may also

result in toxicity due to its high content of vitamin A.

A study in Nepal established that vitamin a supplementation on a weekly basis played a

major role in reducing mortality among pregnant mothers by 40%. The study also showed

that iron deficiency anaemia was significantly reduced from 76% to 69% in pregnant

women who received Vitamin A (Milman et al., 2003). In developing countries, the most

prevalent group of people to anaemia are the pregnant women and women in the

childbearing age bracket. Vitamin A deficiency has been characterized among the leading

causal agents of anaemia. Vitamin A deficiency causes anaemia through haematopoiesis.

This is the increase in the immunity of the body to diseases, hence anaemia through the

modulation process of iron metabolism.

36
Following a study done in Nepal, maternal mortality reduced with about 40% prevalence.

The prevalence in pregnant women reduced from 76%-69% in pregnant women who

received vitamin A supplementation. Increase in dietary intake of vitamin A substance is

known to increase haemoglobin concentrations hence reduce anaemia prevalence. A

similar study in Tanzania showed that intake of other multivitamins other than vitamin A

increased haemoglobin concentration in HIV positive pregnant women. Women who took

vitamin A and iron supplementation weekly had higher iron concentration than women

who took iron supplements daily or weekly. Vitamin A is known to increase iron

absorption and utilization, hence, there is reduction of anaemia levels.

2.4 Maternal Knowledge on Anaemia

Knowledge of anaemia is key to pregnant women during and after childbirth as it

encourages them to take iron supplements that are vital during these periods as it affects

the iron components in the mother and the child. A study carried out in Southern Israel

illustrated that the prevalence of anaemia amongst infants and the level of knowledge in

pregnant women were not closely associated. Little or no information on anaemia

knowledge led to a 12% rise in anaemia cases among infants relative to women with

higher knowledge levels concerning anaemia (Treister-Goltzman, Peleg & Biderman,

2015).

Throughout pregnancy, most women have high blood volumes as well as increased

masses of erythrocytes, an increase of about 45%. Consequently, at pregnancy, women

are usually at a greater anaemia risk, which escalates complications risk contributing to

mortality and morbidity mothers and foetuses. These may include; retardation of foetal

growth, stillbirth and childbirth and maternal deaths. Inadequate knowledge regarding

37
nutrition is considered as a major factor leading to malnourishment, and could activate

complication causing practices. An assessment of the knowledge levels and practices

regarding anaemia among expectant females in Iran showed that only 43.3% of pregnant

women consumed iron supplements appropriately, even though 75.9% of the pregnant

women were aware of the importance of iron during pregnancy. The level of knowledge,

attitudes and practices regarding anaemia is very closely associated and if the level of

aforementioned elements is low, there is a tendency for complications.

According to Mbule et al. (2012), in Uganda, only 80.9% of the respondents had the

knowledge about anaemia. Some of the most recognized symptoms among the

respondents were persistent fatigue, intermittent dizziness and general body weakness.

About 45.1% were aware of three symptoms of anaemia although this knowledge was

inversely related with anaemia presence. Mbule et al. (2012) postulates that most women

have little knowledge concerning the predicaments of anaemia, in terms of what would

happen to them as well as their children. A condition characterized by immoderate blood

loss (haemorrhage) was one of the widespread causes of anaemia. Rajeev et al. (2014)

found out there was inadequate knowledge regarding the causes of anaemia, dietary

requirements to prevent anaemia. Knowledge in relation to anaemia prevention and

treatment was relatively adequate among the people. The findings illustrated that there

existed a direct relation between the women’s knowledge and education on proper diet,

signs & symptoms, prevention, causes and treatment of anaemia.

In Africa, countries have adopted the prevention and treatment of anaemia policies by

providing folic acid and ferrous sulphate to all pregnant women. The most widespread is

iron supplementation in bid to reduce anaemia prevalence among pregnant women. These

38
drugs are offered free of charge to ease access to citizens in the various socio economic

classes in the society.

In pregnancy, most anaemia related cases are recognized in the second and third

trimesters. It has often been associated with unplanned pregnancies. Family planning is

yet to be embraced in developing countries. Most of the pregnancies are experienced

while the mother is still breastfeeding. This results to increased stress to the mother

affecting her nutritional and diet status hence depletion of micronutrient stores in the

mother. This causes the development of anaemia in the first trimester in the succeeding

pregnancy. Folate and iron requirements increase in the last two trimesters of pregnancy.

This requirement can only be met by both diet and from the maternal reserves. Low iron

reserves result to anaemia which escalates in the second and the third trimesters. A

pregnant woman who once had anaemia history is likely to become anaemic in

subsequent pregnancies if not properly examined and treated. Women in the child bearing

age should therefore seek treatment and strictly observe their diet as advised by any

health practitioner.

A study by Souganidis et al. (2012) revealed that maternal knowledge concerning

anaemia has no effect in preventing the mother against anaemia but was found to protect

and prevent children in rural and urban families from anaemia. Other factors that

determined the prevalence of anaemia between mothers and children included the

availability and consumption of fortified milk as well as the availability of improved

latrines. The study established that a pregnant woman’s knowledge on anaemia was

significant to the child’s intake of iron supplementation and fortified milk during the

mother’s last pregnancy. However, the expectant mothers’ knowledge of anaemia was not

39
directly linked to the deworming procedures in the child. Other than in urban families,

maternal knowledge of anaemia was directly related with the intake of animal proteins in

rural families.

Malaria has been a rampant cause of anaemia during pregnancy. Areas with high

prevalence of malaria often experience higher anaemia related cases as compared to areas

with low malaria infection. Malaria is also a risk factor for low birth weights, foetal

anaemia and stillbirths. Micronutrient deficiencies accelerate the prevalence of anaemia

in both the mother and the child. Health care workers in antenatal clinics should educate

pregnant women on the need to take a diversified diet inclusive of all the necessary

dietary requirements.

A recent study showed that 85.7% and 84% of the mothers in urban slums and rural areas

respectively, have ever used and had access to iron supplements during their last

pregnancy. The expectant mothers’ knowledge of anaemia was directly linked to the

intake of animal source foods in the rural areas. Poverty and lack of resources resulted to

a decrease in the consumption of animal source foods, which are vital sources of iron.

Some household preparation and food processing methods are important in increasing the

bioavailability of micronutrients in foods obtained from plants. Such processes include

soaking, germination/malting, mechanical processing and thermal processing. Hence, a

mixed diet of plant source foods and small quantities of animal source foods would

ultimately result to an improvement in micronutrient bioavailability and dietary diversity.

In Mandera County, micronutrient deficiency is a major contributor to pregnant women

anaemia (KNBS, ICF, 2015).

40
2.5 Practice of Intake of Iron Rich Foods among Pregnant Women

It is generally assumed that a balanced amount of nutrients in food is necessary for all

human beings for proper body system functions. This indicates that nutrition is a

fundamental pillar for human beings, for the health and development of entire life.

Nowadays, malnutrition is the great problem in both developed and developing countries.

It is worth noting that obesity and chronic non-communicable diseases are major

problems in developed countries. In developing countries, on the other hand, widespread

under-nutrition and micronutrient deficiencies are common.

It is believed that during pregnancy, it is necessary to have a proper balanced diet to

ensure sufficient energy intake for adequate growth of foetus without drawing on

mother’s own tissues to maintain her pregnancy. Pregnancy is also a period of a

significant increase in iron requirement; the demand is higher due to physiological

changes in maternal red blood cell mass and also due to the needs for the development

and growth of the placenta and foetus. Despite increased iron requirements, pregnancy is

also a period of increased risk for anaemia, which is higher than that of non-pregnant

state.

An increased intake of animal proteins is beneficial in the improvement of health

associated behaviour that has a significant effect in the overall maternal knowledge of

anaemia. Better maternal nutrition can be achieved by adequate consumption of animal

rich foods for better health during pregnancy and lactation to both the mother and the

child. Animal sourced foods have a higher level of bio available micronutrients and they

present a diverse diet option. According to Nyaruhucha (2009), passions and dislikes

among food items is a common phenomenon during pregnancy. The most common

41
during this period are nausea and vomiting. These problems are a source of

embarrassment and are significant in the interference of normal dietary intake which may

at times lead to more critical problems during pregnancy. As a result, health workers

should aid women in their choice towards foods and dietary considerations.

In sub-Saharan Africa, there are multiple causes of anaemia in pregnancy, which include

inadequate diet, iron folate and vitamin B12 deficiencies, impaired micronutrient

absorption, blood loss resulting from hemorrhage, and helminthes infestation. In

Ethiopia, 27% of women are undernourished with a body mass index (BMI) of less than

the 18.5 cut-off point, and only 4% are obese with a BMI of more than 25.0. The major

problems are protein-energy malnutrition and micronutrient deficiencies such as vitamin

A, iron, and iodine. These figures put Ethiopia among sub-Saharan countries with the

highest proportion of malnourished women. Anaemia affects over two billion people

globally, among whom over 40 million are pregnant women. Iron deficiency is thought to

be the most common cause of anaemia, and it accounts for 75%-95% of cases. Research

findings indicate that anaemia affects 57% of pregnant women globally with the highest

prevalence in sub-Saharan Africa.

Anaemia is thought to be an indicator of nutritional deficiencies, which can significantly

contribute to birth defects, preterm labour, and low birth weight, which can, as a result,

cause a global public health problem. However, iron deficiency anaemia (IDA) is a

leading cause of maternal morbidity and mortality, prenatal and prenatal infant loss;

physical and cognitive losses can stall social and economic development in developing

countries. In sub-Saharan countries, the magnitude of anaemia in pregnancy is quite

alarming, whereby its prevalence is widely contributed by poor nutrition, iron and other

42
micronutrients deficiencies, parasitic infestations, chronic infections, illiteracy, and short

pregnancy intervals. Women with IDA may be asymptomatic: however, they are more

susceptible to infection, may tire easily, are prone to an increased chance of preeclampsia

and postpartum haemorrhage, and can poorly tolerate, even a minimal blood loss during

birth. The healing of an episiotomy or an incision is usually delayed, and if the anaemia is

severe, cardiac failure may ensue. Furthermore, there is evidence of increased risk of low

birth weight. In addition, IDA is associated with a higher incidence of low-birth weight

infant’s preterm birth, pre-maturity, stillbirth, and neonatal death in infants of women

with severe iron deficiency.

The prevalence of anaemia in Ethiopian women of 15-49 age groups is 17%. It is 27.9%

in Southeast Ethiopia, lack of awareness is the major retarding factor to reach millennium

development goal, as the awareness of anaemia among pregnant women is only 72%.

Anaemia was found to be a severe public health problem in Ethiopia. More than 40% of

pregnant women are anaemic. It is estimated that iron deficiency and other micronutrients

are the main causes of anaemia throughout the world. It is more common among women

of reproductive age. These deficiencies may lead to birth defects, preterm labour, low

birth weight, resulting in an increase in prenatal death. Many women suffer from a

combination of chronic energy deficiency, poor weight gain in pregnancy, anaemia, and

other micronutrient deficiencies, as well as infections like HIV and malaria. These, along

with inadequate obstetric care, can contribute to high rates of maternal mortality and poor

birth outcomes.

With regard to knowledge concerning iron rich foods, a very few numbers of pregnant

women can identify iron rich foods. Red and organ meat are often despised irrespective

43
of their rich iron contents. ANC clinics should take up the role of educating pregnant

women towards the right nutrition so as to reduce the anaemia prevalence. As a result, the

little knowledge concerning the right nutrition during pregnancy can be attributed to low

attendance of the antenatal clinics. Even on attendance of the antenatal clinics, nutritional

education services are inadequate. Mwadime et al. postulates that the health workers at

the various health facilities are faced with a lot of responsibilities and therefore they have

little or no time to offer health and nutritional education.

Some pregnant women lack the knowledge as to why they should attend antenatal clinics

during the first three months of pregnancy, as it is viewed as majorly curative other than

preventive. As cited by Neema (2013), pregnant women do not seek the antenatal clinic

services as they lack trust of the health system. This is a result of low level services and

medicine unavailability. This has highly contributed to the increased use (73%) of

traditional herbal medicine and services in Uganda as an alternative to antenatal clinic.

Some of these beliefs and practices are the causes of high anaemia incidence in pregnant

women. Poverty is another constraining factor as it reduces the access to timely

information. Poverty leads to inadequate access to sufficient and balanced meals at the

household and individual levels. In addition, iron rich foods such poultry, fish are quite

expensive and individuals at the low ranks of society cannot afford them.

Counselling before pregnancy, nutrition advice and therapy have all proven to result to

successful pregnancy results. Blood count test should be carried out on every visit to the

antenatal clinic and repeated at 28 weeks of pregnancy to check for anaemia so as to treat

it as early as possible. To mothers who are at a higher risk of anaemia such as those with

multiple pregnancies should undergo haemoglobin checks as often times as possible as

44
the delivery approaches. Nutritional advice should be carried out to mothers so that they

can improve their iron food consumption. They should also be advised on the kind of

foods to avoid that are likely to inhibit the consumption of iron. Iron and folic acid

supplements should be administered to all menstruating women in areas where anaemia is

a major health concern. Other health practices such as deworming should be observed to

prevent anaemia. These minerals play a crucial function in embryogenesis and any

deficiencies mainly results in congenital abnormalities. Proper identification of the cause

of anaemia is the first step in finding its cure. During delivery, slowed clamping of the

umbilical cord should be an indicator of neonatal anaemia and therefore necessary

precaution should be taken.

Maternal knowledge of anemia is important because of its potential to encourage women

to take iron supplements during pregnancy and after childbirth, affecting the iron status of

both the mother and the child. In a small study in southern Israel, the presence of anemia

in infants and level of maternal knowledge were inversely related, with low knowledge of

anemia leading to a 12-fold increase in prevalence of anemia in infants compared to

women with higher levels of knowledge.

Increased consumption of animal source foods is an additional health-related behavior

that could be encouraged by maternal knowledge of anemia. Benefits of consuming

animal source foods include dietary diversity, relatively higher bioavailable forms of

micronutrients, and overall better maternal nutrition affecting both the mother and child

during pregnancy and lactation.

Strategies to reduce the prevalence of anemia in children have focused on consumption of

fortified milk by the child and administration of deworming medications. Consumption of

45
fortified milk has already proven to be an effective strategy to reduce anemia in children

and has been the basis for mandatory fortification of powdered milk with iron, vitamins,

and other minerals in Indonesia in the mid-1990s. The use of deworming medications in

endemic areas has also been shown to help improve iron status in children at high risk for

anemia-related morbidity and mortality by reducing the chronic intestinal blood loss

associated with hookworm and other parasitic infections. There is currently no

nationwide deworming policy in Indonesia for children under the age of five. However,

deworming medications are administered by small pilot projects in some areas or by

parents who suspect that their child is infected.

Despite the implementation of large-scale programs targeted towards pregnant women

and women of reproductive age, the prevalence of anaemia remains high. Factors that

limit the success of iron supplementation include inadequate supply, delivery, and

distribution systems, limited access to health care providers and prenatal care, ineffective

social marketing, and overall poor monitoring and evaluation of supplementation

programs. The knowledge and attitudes women hold regarding anaemia may also play a

role in the limited success of these programs.

In a survey conducted in eight developing countries, anaemia was more commonly

recognized by its symptoms instead of by a disease name or clinical diagnosis. Only half

of women considered these symptoms to be of concern, and many women, who took iron

supplements, primarily provided through prenatal care, and did not understand the reason

for treatment. Negative attitudes towards iron supplementation, derived from side effects,

concerns with the tablet’s bad taste, or fears of adverse outcomes, could facilitate non-

compliance, even if the benefits of iron supplementation are known.

46
Despite the fact that anaemia has been identified as a global public health problem for

several years, no rapid progress has been observed, and that the prevalence of the disease

is still high globally. Although there are various intervention methods for the treatment

and prevention of maternal anaemia, there are still many pregnant women affected by

anaemia related health problems, and the contributing factors for the persistence of high

incidences are not empirically known. It is, therefore, vital to devise a method for the

reduction and control of anaemia in women. The need for an educational campaign on the

importance of diversified diet is an aspect that cannot be neglected whatsoever.

Promotion of food items rich in iron has proven success especially in urban areas.

Educational campaigns have proven success among young adolescent girls and helped

improve their nutrition and health.

2.6 Theoretical Framework

Nutrition education programs and interventions established on theory driven models and

research whose aim is to change behaviours receives the most funding. A theory mainly

elaborates on the variables affecting the target behaviour and the relationships among

these variables. A theory explains how to make interventions so as to promote behaviour

change while providing predictability for expected outcomes.

Scholars and researchers in the nutritional community are yet to agree and come up with

a single model as the standard measure for behavioural change. One of the main

challenges has been to consolidate clear structures from the other theories into a single

model that can be empirically tested and improved into a more comprehensive, tailored

theory or set of theories specific to food and nutrition behaviour changes. There are four

behaviour change models commonly used in nutrition and they include: The Health

47
Belief Model (HBM), the Social Cognitive Theory (SCT), the Trans-theoretical model

(TTM) and the Theory of Reasoned Action (TRA).

2.6.1 Health Belief Model

The model originated from the US Public Health Service and was developed in the

1950’s. The theory was constructed to offer an explanation on the prevention health

behaviours as portrayed by various groups of people. Initially, the model was centred on

the association between the health practices, behaviours and the utilization of health

services. However, the model has been shaped to involve health motivation to users so as

to differentiate between health behaviour and illness behaviour. The model illustrates that

benefits and barriers associated with health practices and the perceived susceptibility and

severity aid in the determination of the resultant health behaviours. The model has been

used to train how to stop some behaviours such as smoking, risky behaviours and overall

adolescent health practices.

A more recent version of the Health Belief Model consists of six elements namely cues to

action, perceived benefits, self-efficacy, perceived susceptibility, perceived barriers and

perceived severity. Perceived susceptibility refers to one’s perceptions on the likelihood

that they will encounter a circumstance that will have an adverse effect on their health.

Perceived severity has been termed as an individual’s belief on the extent of development

of a health condition that has affected his/her livelihood. Perceived benefits are individual

opinions on the extent of effectiveness of the recommended solutions and actions at

preventing disease and in reducing the incidence of the negative health effects. Perceived

barriers are the physical and all the psychological costs that are involved and may hinder

one from taking the necessary action. For a change in behaviour to be successful, an

48
individual must be certain that they have the masterly of behaviour (self-efficacy) and

must have established that the benefits associated with change are quite more desirable

than the obstacles even in the face of self-behaviour (perceived susceptibility and

severity) doubt. In addition, internal or external cues are the driving forces in the way of

an individual’s course of action.

The health belief model has proven to be successful in the forecast of behaviour change.

However, a research review indicated that the model yielded very minimal usefulness in

the study concerning the nutrition education arena, specifically related to obesity. The

model has been cited to consist of a number of limitations. Health behaviour is not

directly influenced by belief as people are most likely to act contrary to their personal

convictions. The model neglects other factors that directly influence one’s behaviour such

as past experiences, economic hardships and cultural diversity. These factors have a high

potential of influencing decision making among the study’s target population, hence the

application and use of this model will be limited.

2.6.2 Trans-theoretical Model (TTM)

The model suggests that a change in the balance and an improvement in the confidence

portrayed in the performance of certain tasks whose main aim is change must take place

first before the occurrence of behavioural change. It is one of the most widespread

models that have been in application in both health and nutritional educational sectors. Its

emphasis has been shifted to fruit and vegetable consumption, fat reductions and dietary

fibre intake.

The Trans-theoretical model suggests that behaviour change is associated with five

distinct stages. The stages include pre-contemplation, contemplation, preparation, action

49
and maintenance. Every phase consists of a distinct aspect towards behavioural change. It

consists of experimental and behavioural processes. The change process illustrates the

progress that individuals make from one phase of behavioural change to the next. The

process consists of about ten methods that aid the smooth movement through the phases.

They include self-liberation, stimulus control, self-re-evaluation, social liberation,

dramatic relief, helping relationships, environmental re-evaluation, counter conditioning

and reinforcement management.

The model eludes that the basis of individual decision making is based on the advantages

and the disadvantages associated with behavioural transformation. This goes along with

the ten processes involved for behaviour change to be achieved. At the pre-contemplative

stage, a number of people believe that the less the positive results and the more the

negative outcomes often results to a possibility of behaviour change. Those at the end

stages believe that behaviour change can be achieved when there are more positive

results and less negative outcomes. The theory has been used to predict behaviour

changes in nutritional fat reductions, fruit and vegetable consumption. The theory

emerged from a temporary dimension, various stages of change, integration of principles

and processes from various theories. The theory advanced as a leading theory in

psychology and behavioural change.

2.6.3 Theory of Reasoned Action/ Theory of Planned Behaviour

The theory began as the theory of reasoned action and was used to predict behaviours at a

specific time and place. The theory was aimed at explaining all behaviours that have a

significant effect on self-control. The theory has been used to explain and predict

behaviours associated with smoking, breastfeeding and the efficiency of health services

50
utilization. The theory states that the success behaviour change is dependent on

motivation as well as behavioural control.

The core of TRA is that one’s subjective norms as well as attitude have a notable effect

on the intention behind the performance of certain behaviour. This then is a clear forecast

on the likelihood and possibility for engagement in that particular behaviour. Attitude has

a direct effect on one’s opinion towards engagement in a particular behaviour. Subjective

norms are as a result of societal pressure and forces to either engage or not engage in a

particular behaviour. An effective explanation on the actual behaviour is directly

associated with the extent to which the behaviour is under the control of the individual as

well as the intention that invokes this behavioural change. The Theory of Planned

Behaviour (TPB) was developed in 1986 so as to foretell behaviours over which people

have incomplete volitional control (Ajzen et al, 2009).

Theorists suggest that the ability to control behaviour is the third predictor of the

intention involved before the performance of a particular behaviour. Behaviour control

has been perceived as a representation of activities and circumstances that are beyond the

control of an individual hence affecting both the intention and the behaviour. The theory

exudes a direct relationship between behaviour and the role it plays in behavioural

intention. The behavioural control aspect illustrates the ease or the challenges associated

with the engagement of a particular behaviour pattern. The TPB theory postulates that a

person uses low energy in the engagement of a particular behaviour when their behaviour

control perception is at the lowest, but is likely to put a bit more effort when the

behaviour control is quite higher. Therefore, one’s behaviour intention and control can be

used in behavioural prediction.

51
The TPB theory has proven to be successful in various sectors such as exercise and

nutrition as well as condom usage. Despite the many successes that the model has

achieved so far, it has been marred by a number of challenges and this has exempted it

from the major health behavioural models that most scientists identify with. Success with

the TPB model is only experienced when the behavioural aspect is not affected by

volitional control. In addition, the prediction of real behaviour using the behaviour intent

aspect lowers with time. In conclusion, the scanty definition of behaviour control by

researchers results to a myriad of challenges in its measurement.

2.6.4 Social Cognitive Theory

The theory originates from Miller and Dollard's Social Learning Theory. The social

cognitive theory provides an extensive model explaining health behaviours and methods

to change them. The social cognitive theory comprises of three main aspects namely

environmental factors, individual factors and behavioural repertoires. The three

components are highly dependent on each other and they interact often. The SCT theory

further comprises of behavioural capability, situation and environment, expectations,

reciprocal determinism, expectancies, self-efficacy, observational learning, emotional

coping responses, reinforcement and self-control. The aspect of reciprocal determinism

postulates that the environment, individual and the behavioural repertoire are dynamic in

nature and have direct influences towards one other. One’s behavioural capacity is a

product of personal training, learning style and intellectual capacity.

Self-efficacy involves one’s personal belief in their abilities towards the performance of a

particular obligation. The expectations involved gives people the opportunity to anticipate

what is likely to happen before they can come to it realization. Expectancies are the

52
driving forces that lead to action. They differ from expectations in that they are aimed at a

certain end result. Reinforcements are responses to a person's behaviour that increase or

decrease the likelihood of reoccurrence. An individual may learn from different people by

either received reinforcements or through the observation technique. Observation

involves watching the outcomes and actions of other people’s behaviour. It can only be

highly effective if one identifies a role model from whom they can keenly learn from.

Emotional coping responses are practices adopted by an individual to curb emotional

stimuli.

For successful application of the social cognitive theory, researchers should use a mix of

all the components and should not be limited to only one. The constructs enable social

educators to clearly put their focus on the individual and their environment while at the

same time laying emphasis on a multidimensional tactic towards behavioural change.

Every single construct provides a pathway towards the improvement of all the practices

leading to fully potent health related behaviour.

The provision of role models, construction of behavioural skills and an extension of self-

confidence amidst other improvements in the environment will most likely result to

behaviour change. A number of research studies on health and nutrition education have

been carried out and have justified the success factors associated with SCT. In contrast,

various instruments to measure knowledge and self-efficacy during the interventions

were sourced from earlier research works and developed using various interventions and

quite a number of methodologies.

53
2.7Conceptual Framework

Independent Variables Dependent Variable

Demographic Factors
Age
Marriage
Education,
Income

Vitamin A
Anaemia among Pregnant
Aware of Vit A,
Aware source of Vit Women
A Intake

Personal Factors
Aware Iron diets,
Sources of iron
daily intake

Figure 2. 1: Conceptual Framework

54
 CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Introduction

This chapter discusses the research methodology that was adopted to address the

objectives under this study. The researcher will address research design to be adopted,

respondent’s selection and sampling, methods employed during data collection,

processing and analysis of the problem encountered.

3.2 Study Design

The study will adopt the Cross-sectional descriptive study design. The design is preferred

as it is used to obtain information concerning the current status. The purpose of this

method is to describe what exist with respect to situational variable. According to

Bryman & Bell (2003), in descriptive cross-sectional studies variables that the researcher

is interested in are tested only a single time and the interrelationships are established.

Survey strategy is applied under the deductive approach which allows one to collect

quantitative data which can be analyzed quantitatively using descriptive and inferential

statistics (Saunders et al., 2009)

3.3 Study Site

Mandera County is situated in the previously known North Eastern Province of Kenya.

The county’s capital is Mandera. According to Kenya Census, 2009 the county has a

population of 1,025,756 and an area of 25,797.7 km². It has border Somalia to east and

Ethiopia to north. The county has six sub counties: Mandera South, Mandera North,

Lafey, Banisa and Mandera West.

55
Mandera County Referral Hospital is a Government health centre located in Bulla Power

Sub-location, Bulla Jamhuri location, Central Division, Mandera East Constituency. It

has a total of 128 beds, antenatal care (ANC) services and a basic emergency obstetric

care Caesarean Section. In addition, the facility has a comprehensive emergency obstetric

care, curative outpatient services as well as a curative inpatient facility. The facility also

offers immunization services, family planning, integrated management of childhood

illnesses and an increased growth in the monitoring and promotion of HIV Counselling

and testing. Mandera County Referral Hospital provides health services to its all six sub-

counties Mandera has border with Somalia and Ethiopia. The serves include referrals and

ANC emergency obstetric from these areas so, due to poor of equipment and unskilled

staff at Mandera County during insecurity and long marginalization and negative, cultural

religious practice discourages deliveries at the hospitals. Mothers living in Mandera

County have the highest mortality rate than other counties of Kenya when compared to

the national average (KDHS2014).

3.4 Target population

Ngechu (2004) describes a target population as a categorized group of people, things,

elements, households, services, firms or objects under investigation. A target population

is a population that the researcher seeks to make deductions that are can be theoretically

observed, are countable and occur within a specified timeline. The units under the

timeline ought to be clearly specified (Groves, Fowler, Couper, Lepkowski, Singer, &

Tourangeau, 2009). The target population simply explained is elements relevant to the

research.

56
The study target population of this study constituted of pregnant women in Mandera

County Referral Hospital the estimated number of women pregnant women aged 15-49 is

estimated to be 3651 and they formed the target population for the study.

3.5 Sampling Technique and Sample Size Determination

3.5.1 Sampling Technique

Sampling techniques refers to the various methods used to collect and ascertain the

necessary data from a specified group as compared to all the other possible sources. The

study adopted simple random sampling and convenience sampling techniques. The

convenience sampling approach is preferred due to its ‘accessibility’ nature (Bryman &

Bell, 2003). This study selected every third pregnant woman in the hospital and

questionnaire was administered.

3.5.2 Sample Size Determination

Sample size determination is a key important aspect in the planning of any empirical

study. A sample represents a section of the population, which refers to a theoretical

specified aggregation of a particular element. Therefore, a sample size represents a

fraction of the entire population (Agresti & Finlay, 2009). This study will utilize Fischer’s

formula to compute sample size. According to Fischer et al., (2008) formula, at

permissible error of 5% and prevalence of 50% the sample size was:

Where n = sample size

57
 Z2= Standard error from mean corresponds to 95% confidence interval =1.96, and

is the standard normal deviate (i.e. deviation from the mean in normal distribution

or curve).

p = proportion of the population with the desired characteristics (Prevalence of

anaemia among pregnant in Kenya is at 54%)

q = 1-p =1-0.54=0.46

(0.05) = Permissible error in the estimate of P

Thus, with permissible error of 5%, the sample size is:

Thus, the sample size of 382 was needed.

3.6 Data Collection Tool

A number of techniques have been used in gathering of primary data in descriptive

research design techniques. They include postal and telephone surveys, personal

interviews, observation and self-administered surveys (Roberts-Lombard, 2006).

Collection of primary data was carried out using a simple structured questionnaire. A

structured questionnaire was administered to all eligible women to determine their socio-

demographic and knowledge about the sources iron and challenges in terms of access and

availability diet rich iron.

58
3.7 Data Collection

Primary data collection was carried out using a structured questionnaire that was

developed by the researcher. It captured the knowledge of anaemia and practices foods

that are rich in iron. The research questionnaires were issued out by the researcher as

most of the women in the Mandera County were informally educated and needed

assistance in filling the questionnaire. Data was collected during the months of October

and November 2016, total of the 382 of whom were contested structured questions only

312 provided their responses translated to 81.7% and this attributed to high illiteracy rates

and some of the respondents did not understand the importance of the study. Further,

there was the aspect of language barrier of which most of the respondents only speak

Somali and thus translating the question to the local dialect presented challenges.

3.8 Data Analysis and Presentation

The collected data was presented in frequencies, cross tabulations and diagrams as

necessary. A descriptive analysis included measures of central tendency such as mean,

measures of variability like the standard deviation and range and univariate analysis.

Inferential analysis was carried out using chi square test to determine significant

association between the two variables.

3.9 Ethical Considerations

The KeMU Ethical research committee gave the approval and a go ahead to the

researcher upon meeting key study requirements. An introduction letter was issued by the

University marked addressing the study hospital allowing the researcher to carry out the

study. Respondent’s confidentiality regarding the information they provided was assured.

Privacy of the respondent’s information was guaranteed. After an elaborate explanation

59
concerning the purpose of the study, a written consent was used requesting the patients

for permission to undertake the study. Involvement in the study was on a voluntary basis.

The data collection tools were later kept safely in a place only reachable by the principal

researcher.

60
 CHAPTER FOUR

DATA ANALYSIS AND INTERPRETATION

4.1 Introduction

This chapter introduces the statistical summary and results from empirical analysis.

Further, the chapter entails interpretations of the statistical inferences derived from the

compiled data as the researcher strives to accomplish the objectives of the study.

4.2 Response Rate

The targeted sample size was 382 of who were given self-administered structured

questions of whom 312 provided their responses and this translated to 81.7%. The

researcher used drop and pick technique.

4.3 Bio Data of the Respondents

Table 4.1: Bio Data of the Respondents

Variable Responses Frequency Percent

Age bracket Less than 20 years 34 10.9
Between 21-30 years 76 24.4
Between 31-40 years 126 40.4
More than 40 years 76 24.4
Marital status Single 24 7.7
Married/cohabiting 243 77.9
Divorced/ Separated 33 10.6
Widow 12 3.8
Highest level of Primary level 127 40.7
education achieved Secondary level 63 20.2
University level 12 3.8
Postgraduate 12 3.8
None 42 13.5
College level 56 17.9
Average monthly Less than Ksh 30, 000 151 48.4
income Between Ksh 31,000-60,000 121 38.8
Between Ksh 61,000-90,000 35 11.2
More than Ksh 90,000 5 1.6

61
From the responses in Table 4.1, most of the respondents were between 31-40 years

[40.4%] compared to 24.4% who were between 21-30 years. On their marital status, the

study found that most of the respondents [243, 77.9%] were either cohabiting or married

as opposed to those who were in single motherhood [24, 7.7%] and those who were either

divorced or separated constituted 10.6%. Approximately 190[60.9%] of the respondents

had less than secondary level education and this indicated that the illiteracy level in the

county is high. The last query concerned the monthly income of the respondents. It was

established that majority [151, 48.4%] of the respondents had an average income of less

than Ksh 30,000 while 121[38.8%] indicated that they earned between Ksh 31,000-

60,000 and thus most of the women could afford balanced diet.

4.4 Pregnancy Responses

Table 4.2: Pregnancy Responses

Variable Responses Chi Square Sig. (2-

Frequency Percent Value tailed)
Have you ever been Yes 205 65.7 30.782 .000
pregnant before No 107 34.3
Stage of your First Trimester 79 25.3 47.096 .000
pregnancy Second Trimester 161 51.6
Third Trimester 72 23.1
Number of One pregnancy 69 22.1 143.718 .000
pregnancies had Two pregnancies 156 50.0
before Three
80 25.6
pregnancies
More than four
7 2.2
pregnancies

The Table 4.2 presents the summary of the responses provided by the women on their

state of pregnancy. Most of the respondent were in their second or other pregnancies as

they had been pregnant before [205,65.7%] compared to those in their first pregnancy

62
[107,34.3%] (p =0.000) while on the stage of their pregnancies, slightly more than half

[161,51.6%] were in their second trimester compared to 25.3% in their first trimester (p

<0.05) while half of the respondents indicated that they had a total of two pregnancies,

80(25.6%) had three pregnancies. A significant p value of 0.005 was obtained and this

indicated consistency in the responses provided.

4.5 Diet Rich in Iron Intake

Table 4.3: Responses on the Awareness and Frequency of Intake of Iron Rich Foods

Variable Responses Chi Sig.

Square (2-
Value tailed)

Frequency Percent
Aware of iron Yes 215 31.1 44.628 .000
No 97 68.9
Know the sources of iron Yes 138 44.2 17.154 .000
No 82 26.3
Not sure 92 29.5
Intake frequency iron rich Daily 74 23.7 94.872 .000
foods Weekly 130 41.7
Monthly 96 30.8
Never 12 3.8
Challenges in terms of access Yes 199 63.8 23.705 .000
and availability of iron rich No
source of iron 113 36.2

Table 4.3 shows the responses on the awareness and frequency of intake of iron rich

foods whereby majority (68.9%) of the respondents were not aware of iron (p value

<0.05) and further that 44.2% of the respondents knew the sources of iron compared to

55.8 who neither knew or not sure on the sources (p value >0.05). On the frequencies, the

respondents took the iron rich foods, it was established that majority (130, 41.7%)

indicated they took them weekly compared to 30.8% who cited they took them on

63
monthly basis. It was established majority (199, 63.8%) faced challenges to access and

availability of iron rich foods and thus the need for IFAS or other iron rich supplements.

Figure 4.1: The sources of iron and Percentage

Among the sources of iron both animal and plant based sources that the respondents

indicated they knew about, it was established that 35.3% cited eggs compared to 28.5%

who indicated vegetables as the sources of iron. 19.9% indicated meat as a source of iron

as presented in the Figure 4.3. The responses were significant at 5% as p value obtained

was <0.05.

64
Table 4.4: Intake of Vitamin A

Variable Responses Chi Square Sig. (2-

Frequency Percent Value tailed)

Aware of Vitamin A Yes 249 20.2 110.885 .000
No 63 79.8
Aware of sources of Yes 300 3.8 265.846 .000
No
Vitamin A 12 96.2

Intake frequency of Daily 132 42.3 67.385 .000

Weekly 144 46.2
those foods Monthly 36 11.5
Challenges in terms of Yes 230 73.7 70.205 .000
No
access and availability of
82 26.3
Vitamin A
The Table 4.5 presents the responses on the intake of Vitamin A among the pregnant

women in Mandera Referral County Hospital. Most of the women (249, 79.8%) were not

aware of Vitamin A and further 96.2% were not aware of the various sources of Vitamin

A and these responses were significant at 5%. On the query about frequency of intake of

Vitamin A, it was established that majority 46.2% and 42.3% took foods rich in Vitamin

A on weekly and daily basis. Further, most (230, 73.7%) of the respondents indicated that

they experienced challenges in terms of access and availability of Vitamin.

65
4.6 Folate or Folic Acid

Table 4.5: Folic Acid Awareness among pregnant women

Variable Responses Chi Sig. (2-

Square tailed)
Frequency Percent Value
Aware of Folate or Yes 224 28.2 59.282 .000
Folic Acid No 88 71.8
Types of foods and Fruit 288 92.3 138.481 .000
drinks do you think Green vegetables 123 39.4
are good sources of Milk 89 28.5
folate Fish/Seafood 36 11.5
Meat 78 25
Breakfast cereals 8 0.025
Bread 39 12.5
Health problems are Arthritis 39 12.5 4.459 .000
associated with lack Neural Tube Defects
200 64.1
of enough folate/folic (Spina bifida)
acid in the diet Goiter (enlarged
73 23.4
thyroid gland)

Approximately 72% the respondents who indicated that they were not aware of folate or

folic acid compared to 28.2% who indicated that they were aware. Among the foods, the

respondents were aware or knew as good sources of folate, 92.3% indicated fruits

compared to 39.4% who indicated green vegetables while 28.5% indicated milk.

Assessing knowledge of health problems are associated with not having enough

folate/folic acid in the diet, majority (64.1%) indicated Neural Tube Defects (for

example, Spina bifida) compared to 23.4% who said Goiter (enlarged thyroid gland). All

the responses were significant at 5% level.

66
Figure 4.2: Knowledge of health problems associated with lack of enough folate/folic

acid in the diet

4.7 Cross tabulations

Cross tabulations are simply data tables that present the results of the entire group of

respondents as well as results from sub-groups of survey respondents. The Tables that

follows presents the cross tabulation between social demographic data and awareness of

iron, folic acid vitamin A.

67
4.7.1 Cross tabulations of Age and Nutrients Awareness

Table: 4.8.1: Age Bracket and Nutrient Awareness

Aware of micronutrient Chi- Std

iron Square
Dev
No. of Years Yes No Total
Less than 20 years 26 8 34 1.057a .788
Between 21-30
52 24 76
years
Between 31-40
86 40 126
years
More than 40 years 51 25 76
Aware of Vitamin A
Less than 20 4.785a .188
28 6 34
years
Between 21-30
54 22 76
years
Between 31-40
104 22 126
years
More than 40
63 13 76
years
Aware of Folate or Folic
Acid
Less than 20 years 25 9 34 8.196a .042
Between 21-30
55 21 76
years
Between 31-40
81 45 126
years
More than 40
63 13 76
years
Total 224 88 312

68
4.7.2 Cross tabulations of Marital Status and Nutrient Awareness

Table: 4.8.2: Marital Status and Nutrient Awareness

Chi- Std
Aware of micronutrient Square
iron Dev

No. of Years Yes No Total

Marital Single 17 7 24 .683a .877

status
Married/cohabiting 168 75 243
Divorced/ Separated 21 12 33
Widow 9 3 12
Aware of Vitamin A
marital status Single 17 7 24 1.921a .589
Married/cohabitin
195 48 243
g
Divorced/
28 5 33
Separated
Widow 9 3 12
Aware of Folate or Folic
Acid
marital status Single 16 8 24 3.027a .387
Married/cohabiting 174 69 243
Divorced/
27 6 33
Separated
Widow 7 5 12
Total 224 88 312

69
4.7.3 Cross Tabulations of Education Level and Nutrient Awareness

Table: 4.8.3 Education Level and Awareness

Aware of micronutrient Chi- Std

called iron Square Dev
Highest level of education achieved Yes No Total
Primary level 79 48 127 8.375a .137
Secondary level 51 12 63
University level 8 4 12
Postgraduate 8 4 12
None 27 15 42
College level 42 14 56
Aware of Vitamin A
Primary level 94 33 127 7.292a .200
Secondary level 51 12 63
University level 11 1 12
Postgraduate 12 0 12
None 35 7 42
College level 46 10 56
Aware of Folate or Folic
Acid
Primary level 92 35 127 9.562a .089
Secondary level 49 14 63
University level 8 4 12
Postgraduate 12 0 12
None 29 13 42
College level 34 22 56
Total 224 88 312

CHAPTER FIVE

DISCUSSIONS, CONCLUSIONS & RECOMMENDATIONS

5.2 Discussions

Majority (68.9%) of the respondents were not aware of iron (p value <0.05) and further

that 44.2% of the respondents knew the sources of iron compared to 54.8% who neither

70
knew or not sure on the sources (p value >0.05). This concurred with Brabin et al. (2008)

who noted that most of women in developing countries especially in the marginalized

areas were not aware of iron. On the frequencies, the respondents took the iron rich

foods, it was established that majority (130, 41.7%) indicated they took them weekly

compared to 30.8% who cited they took them on monthly basis. It was established

majority (199,63.8%) faced challenges to access and availability of iron rich foods and

thus the need for IFAS or other iron rich supplements. most of the women (249,79.8%)

were aware of Vitamin A and further 96.2% were aware of the various sources of Vitamin

A and these responses were significant at 5%. On the query about frequency of intake of

Vitamin A, it was established that majority 46.2% and 42.3% took foods rich in Vitamin

A on weekly and daily basis. Further, most (230, 73.7%) of the respondents indicated that

they experienced challenges in terms of access and availability of Vitamin A. the study

agrees with Milman et al. (2003) who noted that weekly vitamin A supplementation

reduced maternal mortality by 40% and further most women may not know they have

deficiency of the vitamin and presented in this study.

Approximately 72% the respondents who indicated that they were aware of folate or folic

acid compared to 28.2% who indicated that they were not aware. Among the foods, the

respondents were aware or knew as good sources of folate, 92.3% indicated fruits

compared to 39.4% who indicated green vegetables while 28.5% indicated milk.

Assessing knowledge of health problems are associated with not having enough

folate/folic acid in the diet, majority (64.1%) indicated Neural Tube Defects (like spina

bifida) compared to 23.4% who said Goiter (enlarged thyroid gland). All the responses

were significant at 5% level. Though few studies have assessed the folate knowledge,

71
Cook (2004) indicated that Folate requirements are 5-to 10-fold higher in pregnant than

in non-pregnant women, therefore pregnant women may be at risk for folate deficiency,

and from this study, it is evident that women from Mandera community have little

knowledge and their practice is sub optimal on it and thus they may be suffering from its

deficiency.

5.1 Introduction

The chapter presents summary of the study findings and the conclusions arrived at. The

chapter also gives recommendations and the suggestions for further study. The discussion

is guided by the study objectives

5.3 Conclusions

Most of the respondent was in their second or other pregnancies as they had been

pregnant before compared to those in their first pregnancy. On the stage of their

pregnancies, slightly more than half were in their second trimester compared to a quarter

in their first trimester That majority of the respondents were aware of iron and further that

less than half of the respondents knew the sources of iron compared to more than half

who neither knew or not sure on the sources. Majority faced challenges to access and

availability of iron rich foods and thus the need for IFAS or other iron rich supplements.

Knowledge on anaemia: Majority of the pregnant women do not have any knowledge on

anaemia and its effects in pregnancy, which influences the importance to which they

attach to the supplements.

Most of the women were not aware of Vitamin A and further some of them were aware of

the various sources of Vitamin A and these responses were significant at 5%. Majority

they don’t take foods rich in Vitamin A on daily basis. Most respondents who indicated

72
 that they were not aware of folate or folic acid compared to 28.2% who indicated that

they were aware. Among the foods, the respondents were aware or knew as good sources

of folate, most indicated fruits compared to a third who indicated green vegetables while

28.5% indicated milk

5.4 Recommendations

i. Health professionals at the health facility should sensitize pregnant women on the need

to continuously take the supplements throughout pregnancy. To ensure that the

pregnant women actually take the supplements, education on anaemia in relation to

pregnancy should be done. Training to the health professionals and community health

workers in regard to anaemia, nutrition during pregnancy and counselling skills to be

applied when they come in contact with the mothers.

ii. Education on anaemia prevention should be emphasized in the community level in

order to encourage dietary modifications and promote environmental control of

infections contributing to anaemia. This needs to be carried out on a continuous basis

and integrated with other ongoing community health programmes.

iii. Subsequent studies should be undertaken by the Ministry of Health (MoH) and other

research bodies on the iron/folate supplementation program for the improvement of

maternal health and on dietary adequacy.

73
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80
 APPENDICES

APPENDIX I: CONSENT FORM

My name is Abdirizak Haji Mohamed, a master student in Kenya Methodist University.

I’m undertaking a study on the factors leading to anaemia among pregnant women in

Mandera County. The aim of this survey is to determine the knowledge of anaemia and

nutritional causes of anaemia among pregnant women in Mandera Referral County

Hospital. I wish to request for your voluntary participation and consent in regard to this

study.

 You are free to choose either to participate or decline to participate.

 There will be no payment for those who choose to participate.

 Information given was treated with utmost confidentiality and was used for the

purpose of the study only.

 No names will be used to identify you and the information gathered will help

enhance better understanding of the study topic.

 You may refuse to answer any question or withdraw from the study at any time.

 There will no alteration of data during analysis and after the study; the researcher

will give feedback to the hospital for necessary action.

Having read and understood the above information and that the study is voluntary,

confidentiality and anonymity are guaranteed, I do hereby accept to participate in this

research study.
Participant’s sign……………………………… Date…………………………..
Principal researcher’s sign……………………… Date……………………………

81
 APPENDIX II: RESEARCH QUESTIONNAIRE

Demographic Information

1. What is your age bracket?

Less than 20 years [ ]

Between 21-30 years [ ]

Between 31-40 years [ ]

More than 40 years [ ]

2. What is your marital status?

Single [ ]

Married/cohabiting [ ]

Divorced/ Separated [ ]

Widow [ ]

3. What is the highest level of education you have achieved?

Primary level [ ]

Secondary level [ ]

University level [ ]

Postgraduate [ ]

82
 None [ ]

4. What is your average monthly income?

Less than Ksh 30, 000 [ ]

Between Ksh 31,000-60,000 [ ]

Between Ksh 61,000-90,000 [ ]

More than Ksh 90,000 [ ]

5. Have you been pregnant before

Yes [ ]

No [ ]

6. What is the stage of your pregnancy?

First Trimester [1Months-3Month]

Second Trimester [3Month-6months]

Third Trimester [6Month-9Months]

7. If yes, to the above question, how many previous pregnancies have you had?

One pregnancy [ ]

Two pregnancies [ ]

Three pregnancies [ ]

More than four pregnancies [ ]

83
INTAKE OF IRON

8. Are you aware of micronutrient called iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

9. Do you know the sources of iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

If yes, which are the sources of iron both animal and plant based sources?

Fruit [ ]

Vegetables [ ]

Eggs [ ]

Meat [ ]

Salt [ ]

Milk [ ]

10. What is your intake frequency of those foods?

Daily [ ]

84
 Weekly [ ]

Monthly [ ]

Never [ ]

11. Do you have any challenges in terms of access and availability of iron rich

source of iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

INTAKE OF VITAMIN A

12. are you aware of Vitamin A

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

13. are you aware of sources of Vitamin A

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

14. What are the main sources of Vitamin A?

Fruit [ ]

85
 Green vegetables [ ]

Orange vegetables [ ]

Yellow vegetables [ ]

Tomato [ ]

Dairy products [ ]

Liver [ ]

Fish [ ]

Fortified cereals [ ]

15. What is your intake frequency of those foods?

Daily [ ]

Weekly [ ]

Monthly [ ]

Never [ ]

16. Do you have any challenges in terms of access and availability of iron rich

source of iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

86
INTAKE OF FOLATE

17. Are you aware of Folate or Folic Acid?

Yes [ ]

No [ ]

Don’t Know/Not sure [ ]

18. Which types of foods and drinks do you think are good sources of folate?

Fruit [ ]

Green vegetables [ ]

Milk [ ]

Fish/Seafood [ ]

Meat [ ]

Breakfast cereals [ ]

Bread [ ]

19. Which health problems are associated with not having enough folate/folic

acid in the diet? (More than one answer can be ticked)

Arthritis [ ]

Neural Tube Defects (Spina bifida) [ ]

Goitre (enlarged thyroid gland) [ ]

Mental retardation [ ]

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